ࡱ> y bjbj s{{gD  vvvvv$PD.!">(>>>@F&fG HT<>>>>>>$ byvN>D@FNNbvv>>tttNv>v><tN<tt>`XzOL(0!qsP.qqv0 ^H@JXtKLQ^H^H^Hbbb"^H^H^H!NNNNq^H^H^H^H^H^H^H^H^H <:  FORMCHECKBOX  Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258  FORMCHECKBOX  Scottsdale Indemnity Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Adm. Office: 8877 North Gainey Center Drive  FORMCHECKBOX  Scottsdale Surplus Lines Insurance Company Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 Scottsdale, Arizona 85258 1-800-423-7675 Fax (480) 483-6752 www.scottsdaleins.com Auto Service Risks Application Applicant s Name:  FORMTEXT        FORMTEXT       Mailing Address:  FORMTEXT        FORMTEXT       Location Address:  FORMTEXT        FORMTEXT       Web site Address:  FORMTEXT       Agency Name:  FORMTEXT       Agent:  FORMTEXT       Address:  FORMTEXT        FORMTEXT       E-mail:  FORMTEXT       Phone:  FORMTEXT       PROPOSED EFFECTIVE DATE: From  FORMTEXT       To  FORMTEXT       12:01 A.M., Standard Time at the address of the Applicant ANSWER ALL QUESTIONS IF THEY DO NOT APPLY, INDICATE "NOT APPLICABLE" Applicant is:  FORMCHECKBOX  Individual  FORMCHECKBOX  Corporation  FORMCHECKBOX  Partnership  FORMCHECKBOX  Joint Venture  FORMCHECKBOX  Limited Liability Company  FORMCHECKBOX  Other (Specify):  FORMTEXT       A. GENERAL INFORMATION: 1. Number of years in business:  FORMTEXT     Number of years at this location:  FORMTEXT     2. Indicate operations applicable to applicant:  FORMCHECKBOX  Automobile Parts & Supplies Store  FORMCHECKBOX  Automobile Quick Lubrication Services  FORMCHECKBOX  Automobile Repair or Service Shop  FORMCHECKBOX  Automobile Storage  FORMCHECKBOX  Car Washother than self-service  FORMCHECKBOX  Car Washself-service  FORMCHECKBOX  Convenience Store/Gasoline Stationfull servicewith service/repair shop  FORMCHECKBOX  Convenience Store/Gasoline Stationself and full service combinedwith service/repair shop  FORMCHECKBOX  Convenience Store/Gasoline Stationself-servicewithout service/repair shop (refer to Grocery/Convenience Store Program) FORMCHECKBOX  Gasoline Stationfull servicewith service/repair shop  FORMCHECKBOX  Gasoline Stationself and full service combinedwith service/repair shop  FORMCHECKBOX  Gasoline Stationself-servicewithout convenience store and no service/repair shop  FORMCHECKBOX  Mobile Repair/Detailing  FORMCHECKBOX  Parkingpublicnot open air  FORMCHECKBOX  Parking public open air  FORMCHECKBOX  Roadside Assistance  FORMCHECKBOX  Tire Dealer  FORMCHECKBOX  Other (describe):  FORMTEXT       3. Inspection Contact Person:  FORMTEXT       Telephone:  FORMTEXT       4. Does applicant have any vehicle dealer operations?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 5. Does applicant have other business ventures for which coverage is not requested?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, explain and advise where insured:  FORMTEXT      6. Any other insurance with this company or being submitted?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, please list name[s] and/or policy number[s]:  FORMTEXT       7. During the past three years, has any company canceled, declined or refused similar insurance to the applicant (Not Applicable in Missouri)?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, explain:  FORMTEXT      8. Does risk engage in the generation of power, other than emergency back-up power, for their own use or sale to power companies?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, describe:  FORMTEXT      9. Additional Insured Information: NameAddressInterest FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      10. Prior Carrier Information: Year:  FORMTEXT     Year:  FORMTEXT     Year:  FORMTEXT     Carrier FORMTEXT       FORMTEXT       FORMTEXT      Policy Number FORMTEXT       FORMTEXT       FORMTEXT      Coverage FORMTEXT       FORMTEXT       FORMTEXT      Total Premium$ FORMTEXT      $ FORMTEXT      $ FORMTEXT      11. Loss History: Indicate all claims or losses (regardless of fault and whether or not insured) or occurrences that may give rise to claims for the prior three years.  FORMCHECKBOX  Check if no losses in the last three years Date of LossDescription of LossAmount PaidAmount ReservedClaim Status (Open or Closed) FORMTEXT       FORMTEXT      $ FORMTEXT      $ FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      $ FORMTEXT      $ FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      $ FORMTEXT      $ FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      $ FORMTEXT      $ FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      $ FORMTEXT      $ FORMTEXT       FORMTEXT       B. OPTIONAL MARKET SEGMENTS ENDORSEMENTS 1. MS AS 01 (or state equivalent)Auto Service Risks (Property Coverage extensions) Coverage Selected?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 2. Increased Limits for Optional Auto Services Endorsement MS AS 01 (or state equivalent): Premises No.:  FORMTEXT    Building No.:  FORMTEXT    Limit of InsuranceIncreased Limits Available1. Fire Department Service Charge$ FORMTEXT      ($7,500 or $10,000 limits)2. Money and Securities$ FORMTEXT      (maximum limit $10,000)3. Outdoor Signs$ FORMTEXT      (maximum limit $250,000)4. Valuable Papers and Records$ FORMTEXT      (maximum limit $250,000)5. Employee Tools$ FORMTEXT      ($5,000, $7,500 or $10,000 limits)6. Accounts Receivable$ FORMTEXT      (maximum limit $250,000) Premises No.:  FORMTEXT    Building No.:  FORMTEXT    Limit of InsuranceIncreased Limits Available1. Fire Department Service Charge$ FORMTEXT      ($7,500 or $10,000 limits)2. Money and Securities$ FORMTEXT      (maximum limit $10,000)3. Outdoor Signs$ FORMTEXT      (maximum limit $250,000)4. Valuable Papers and Records$ FORMTEXT      (maximum limit $250,000)5. Employee Tools$ FORMTEXT      ($5,000, $7,500 or $10,000 limits)6. Accounts Receivable$ FORMTEXT      (maximum limit $250,000)3. Loss or Damage to Customers Autos: Select Coverage Requested:  FORMCHECKBOX  MS AS 02 Direct primary coverage for loss or damage to customers autos.  FORMCHECKBOX  MS AS 03 Legal liability coverage for loss or damage to customers autos.  FORMCHECKBOX  MS AS 04Direct primary coverage for loss or damage to customers autos and other customers property.Requested Limits and DeductiblesLoc. 1Loc. 2Enter the Limit for Each Location (maximum value of all autos in your C.C.C.)$ FORMTEXT      $ FORMTEXT      Maximum number of vehicles in your C.C.C. FORMTEXT       FORMTEXT      Other than Collision deductible per each customer s auto$ FORMTEXT      $ FORMTEXT      Other than Collision maximum deductible per any one event$ FORMTEXT      $ FORMTEXT      Other than Collision deductible per each customer s auto with no maximum per event. (ten percent (10%) rates credit available)$ FORMTEXT      $ FORMTEXT      Collision deductible per each customer s auto$ FORMTEXT      $ FORMTEXT      4. MS AS 05 Loss or Damage to Lessors Property: Loc. 1Loc. 2Description of Premises FORMTEXT       FORMTEXT      Description of Leased Property FORMTEXT       FORMTEXT      Name of Lessor FORMTEXT       FORMTEXT      Limit of Insurance per Occurrence (maximum limit $100,000)$  FORMTEXT      $  FORMTEXT       5. MS AS 06 (or state equivalent) Hired Auto and Non-Owned Auto Liability: CoveragePer Occurrence Limit of Insurance (maximum per occurrence limit $1,000,000)Hired Auto Liability Cost of Hire: $ FORMTEXT      $ FORMTEXT      Non-Owned Auto Liability No. of Employees:  FORMTEXT      $ FORMTEXT      C. PROPERTY SECTION 1. Equipment Breakdown Coverage requested?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 2. Premises information: a.Premises No.:  FORMTEXT    Building No.:  FORMTEXT    Interest:  FORMTEXT       Address:  FORMTEXT      CoverageAmount RequestedCoins. %ACV/Repl. CostCause of LossDeductibleBuilding$ FORMTEXT       FORMTEXT    %$ FORMTEXT       FORMTEXT      $ FORMTEXT      Business Personal Property$ FORMTEXT       FORMTEXT    %$ FORMTEXT       FORMTEXT      $ FORMTEXT      Business Income$ FORMTEXT       FORMTEXT    %N/A FORMTEXT      N/AOther$ FORMTEXT       FORMTEXT    %$ FORMTEXT       FORMTEXT      $ FORMTEXT      " Mortgagee or loss payee:  FORMTEXT       " Construction type:  FORMTEXT       " Protection class:  FORMTEXT       " Number of stories:  FORMTEXT     " Total square foot area:  FORMTEXT       " Sprinkler system?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Operable smoke detectors?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Is structure enclosed?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Spray painting operations?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, is spray paint booth UL approved?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Burglar alarm type:  FORMCHECKBOX  Local  FORMCHECKBOX  Central Station Fire alarm type:  FORMCHECKBOX  Local  FORMCHECKBOX  Central Station Year built:  FORMTEXT      " Building remodeling (include year): Wiring?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Year:  FORMTEXT      Heating?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Year:  FORMTEXT      Plumbing?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Year:  FORMTEXT      Roof?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Year:  FORMTEXT      " Are flammables stored in separate, well ventilated fire divisions away from ignition sources in accordance with state specific guidelines?  FORMCHECKBOX  Yes  FORMCHECKBOX  No b.Premises No.:  FORMTEXT    Building No.:  FORMTEXT    Interest:  FORMTEXT       Address:  FORMTEXT      CoverageAmount RequestedCoins. %ACV/Repl. CostCause of LossDeductibleBuilding$ FORMTEXT       FORMTEXT    %$ FORMTEXT       FORMTEXT      $ FORMTEXT      Business Personal Property$ FORMTEXT       FORMTEXT    %$ FORMTEXT       FORMTEXT      $ FORMTEXT      Business Income$ FORMTEXT       FORMTEXT    %N/A FORMTEXT      N/AOther$ FORMTEXT       FORMTEXT    %$ FORMTEXT       FORMTEXT      $ FORMTEXT      " Mortgagee or loss payee:  FORMTEXT       " Construction type:  FORMTEXT       " Protection class:  FORMTEXT       " Number of stories:  FORMTEXT     " Total square foot area:  FORMTEXT       " Sprinkler system?  FORMCHECKBOX  Yes  FORMCHECKBOX  No " Operable smoke detectors?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Is structure enclosed?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Spray painting operations?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, is spray paint booth UL approved?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Burglar alarm type:  FORMCHECKBOX  Local  FORMCHECKBOX  Central Station Fire alarm type:  FORMCHECKBOX  Local  FORMCHECKBOX  Central Station Year built:  FORMTEXT      " Building remodeling (include year): Wiring?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Year:  FORMTEXT      Heating?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Year:  FORMTEXT      Plumbing?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Year:  FORMTEXT      Roof?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Year:  FORMTEXT      " Are flammables stored in separate, well ventilated fire divisions away from ignition sources in accordance with state specific guidelines?  FORMCHECKBOX  Yes  FORMCHECKBOX  No D. GENERAL LIABILITY SECTION 1. Limits Of Liability & Deductible Requested: General Aggregate (other than Products/Completed Operations)$ FORMTEXT      Products & Completed Operations Aggregate$ FORMTEXT      Personal & Advertising Injury (any one person or organization)$ FORMTEXT      Each Occurrence$ FORMTEXT      Damage To Premises Rented To You (any one premise)$ FORMTEXT      Medical Expenses (any one person)$ FORMTEXT      Deductible$ FORMTEXT      2. Schedule of Hazards: Loc. No.Classification DescriptionClass. CodeExposurePremium Basis (s) Gross Sales (p) Payroll (a) Area (c) Total Cost (t) Other (identify) FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      3. Does applicant have any owned commercial vehicles?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 4. Does applicant subcontract work to others?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, advise total cost and details:  FORMTEXT       5. Does applicant store oil, gasoline or other petroleum products?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, explain:  FORMTEXT      6. Does applicant rent or loan autos to customers while their autos are left for service or repair?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, explain:  FORMTEXT      7. Does applicant pick up or deliver automobiles?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, indicate radius in miles: 50 mi  FORMTEXT    % 50-200  FORMTEXT    % over 200  FORMTEXT    % 8. Are any automobiles consigned?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 9. Where are keys to customers autos kept: At night?  FORMTEXT       During business hours?  FORMTEXT       10. Where are customers autos kept at night?  FORMCHECKBOX  Inside  FORMTEXT    %  FORMCHECKBOX  Outside  FORMTEXT    % 11. If autos are kept outside, is lot protected on all sides by fence, chain, cable or pipe welded to or connected through steel, concrete or heavy timber post and secured with a heavy gauge steel padlock?  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r>*B*OJQJUph.jhN>*B*OJQJUmHnHphunn o2p&*r*z$ ()0*d$If^`a$gd4 ()0* (%d<](^`%gd>y P$%d^`%gd>y$ 0*8d^8`a$gd>y$ 0*8d<^8`a$gd>yzo|o~ooooooooooooooooo p pp"p$p&p,pضiVضAi)jQhN>*B*OJQJUph$jhsyhNB*Uph.jhN>*B*OJQJUmHnHphu)jOhN>*B*OJQJUphhj>*B*OJQJph#jhj>*B*OJQJUphhsyhV>*B*CJph$jhsyhNB*UphhsyhVB*phjhsyhk4B*UphhsyhV5B*ph,p.p0p2p6p8p:pqqqqqqqqr****&***J*L*`*ʽ׽׭ך׭טׅpeRDh4B*OJQJ^Jph$jh4B*OJQJU^Jphhsyh )B*ph)jhsyhB*UmHnHphu$jShsyhNB*UphU$jhsyhNB*Uphjhsyhk4B*Uphhsyh1&5B*phhsyh>y5B*phhsyh1&B*phhsyhVB*ph#jhj>*B*OJQJUphFORMCHECKBOX  No If no, explain:  FORMTEXT      12. Is the parking area lighted at night?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 13. Are there any dogs on premises?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 14. Does applicant employ a guard while business is closed?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 15. Advise if applicant has the following operations: " Airbag installation, servicing or repair?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, advise percentage of gross receipts:  FORMTEXT    % " Aircraft servicing or repair?  FORMCHECKBOX  Yes  FORMCHECKBOX  No " All terrain vehicle (ATV) service or repair?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, advise percentage of gross receipts:  FORMTEXT    % " Alternative fuel conversions (butane, propane or liquid petroleum)?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, advise percentage of gross receipts:  FORMTEXT    % " Auto or Van conversions/modifications:  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, advise percentage of gross receipts:  FORMTEXT    % Indicate type of work performed and/or equipment installed:  FORMCHECKBOX  Air Conditioners  FORMCHECKBOX  High valued electronics  FORMCHECKBOX  Stoves  FORMCHECKBOX  Chair lifts  FORMCHECKBOX  Hydraulic suspension systems  FORMCHECKBOX  Structural  FORMCHECKBOX  Chassis  FORMCHECKBOX  Performance  FORMCHECKBOX  Style  FORMCHECKBOX  Frame  FORMCHECKBOX  Physically disabled controls  FORMCHECKBOX  Suspension  FORMCHECKBOX  Handling characteristics  FORMCHECKBOX  Refrigerators  FORMCHECKBOX  Tanks  FORMCHECKBOX  Heaters  FORMCHECKBOX  Other (describe):  FORMTEXT       " Automobile dismantling?  FORMCHECKBOX  Yes  FORMCHECKBOX  No " Automobile repair shops self service?  FORMCHECKBOX  Yes  FORMCHECKBOX  No " Auto rebuilding?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, advise percentage of gross receipts:  FORMTEXT    % Indicate all applicable:  FORMCHECKBOX  Custom work  FORMCHECKBOX  Flood restoration  FORMCHECKBOX  Fire restoration  FORMCHECKBOX  Salvaged titled vehicles  FORMCHECKBOX  Other (describe):  FORMTEXT       " Boat service or repair?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, advise percentage of gross receipts:  FORMTEXT    % " Bus service or repair?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, advise percentage of gross receipts:  FORMTEXT    % " Contractors equipment service or repair?  FORMCHECKBOX  Yes  FORMCHECKBOX  No " Farm equipment service or repair?  FORMCHECKBOX  Yes  FORMCHECKBOX  No " Frame straightening?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, advise percentage of gross receipts:  FORMTEXT    % " Heavy truck service or repair?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, advise percentage of gross receipts:  FORMTEXT    % " Impound storage lots?  FORMCHECKBOX  Yes  FORMCHECKBOX  No " Interlock breathalyzer installation service or repair?  FORMCHECKBOX  Yes  FORMCHECKBOX  No " Jet ski service or repair?  FORMCHECKBOX  Yes  FORMCHECKBOX  No " Leasing or renting of vehicles or equipment?  FORMCHECKBOX  Yes  FORMCHECKBOX  No " Liquor sales?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, advise percentage of gross receipts:  FORMTEXT    % Manufacturing, assembling or fabrication operations?  FORMCHECKBOX  Yes  FORMCHECKBOX  No " Mobile equipment service or repair?  FORMCHECKBOX  Yes  FORMCHECKBOX  No " Mobile home service or repair?  FORMCHECKBOX  Yes  FORMCHECKBOX  No " Motorcycle service or repair?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, advise percentage of gross receipts:  FORMTEXT    % " Motorcycle manufacturing, assembly, fabrication or performance enhancement?  FORMCHECKBOX  Yes  FORMCHECKBOX  No " Motorhome/RV service or repair?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, advise percentage of gross receipts:  FORMTEXT    % " Parking garages/Lots other than self-park?  FORMCHECKBOX  Yes  FORMCHECKBOX  No " Pawn shop operations?  FORMCHECKBOX  Yes  FORMCHECKBOX  No " Racing operations?  FORMCHECKBOX  Yes  FORMCHECKBOX  No " Repossession operations?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, advise percentage of gross receipts:  FORMTEXT    % " Salvage or junk yards?  FORMCHECKBOX  Yes  FORMCHECKBOX  No " Snowmobile service or repair?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, advise percentage of gross receipts:  FORMTEXT    % " Is applicant a member of the Tire Industry Association (TIA)?  FORMCHECKBOX  Yes  FORMCHECKBOX  No " Tire recapping/retreading or split rim work?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Used Tire sales?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, advise percentage of gross receipts:  FORMTEXT    % " Tow truck operations?  FORMCHECKBOX  Yes  FORMCHECKBOX  No " Trailer hitch bolt-on installation or repair?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, advise percentage of gross receipts:  FORMTEXT    % " Trailer hitch weld-on operations?  FORMCHECKBOX  Yes  FORMCHECKBOX  No " Trailer service or repair for other than utility trailers?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, advise percentage of gross receipts:  FORMTEXT    % " Travel trailer service or repair?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, advise percentage of gross receipts:  FORMTEXT    % " Truck tractor service or repair?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, advise percentage of gross receipts:  FORMTEXT    % " Valet Parking?  FORMCHECKBOX  Yes  FORMCHECKBOX  No " Watercraft service or repair?  FORMCHECKBOX  Yes  FORMCHECKBOX  No This application does not bind YOU nor US to complete the insurance, but it is agreed that the information contained herein shall be the basis of the contract should a policy be issued. FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. Notice To Florida Applicants: Any person who knowingly and with intent to injure, defraud, or deceive any in- surer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony in the third degree. APPLICABLE IN HAWAII (AUTOMOBILE): For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Notice To Maine Applicants: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. NOTICE TO MARYLAND APPLICANTS: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. NOTICE TO OHIO APPLICANTS: Any person who knowingly and with intent to defraud any insurance company files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. FRAUD WARNING (APPLICABLE IN TENNESSEE, VIRGINIA AND WASHINGTON): It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. FRAUD WARNING APPLICABLE IN THE STATE OF NEW YORK (OTHER THAN AUTOMOBILE): Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. FRAUD WARNING APPLICABLE IN THE STATE OF NEW YORK (AUTOMOBILE): Any person who knowingly and with intent to defraud any insurance company or other person files an application for commercial insurance or a statement of claim for any commercial or personal insurance benefits containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person who, in connection with such application or claim, knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation. APPLICANT S NAME AND TITLE:  FORMTEXT       APPLICANT S SIGNATURE: DATE:  FORMTEXT       (Must be signed by an active owner, partner or executive officer) PRODUCER S SIGNATURE: DATE:  FORMTEXT       AGENT NAME:  FORMTEXT       AGENT LICENSE NUMBER:  FORMTEXT       (Applicable to Florida Agents Only) IMPORTANT NOTICEAs part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning character, general reputation, personal characteristics and mode of living. Upon written request, additional information as to the nature and scope of the report, if one is made, will be provided.     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P 9 0&P1h:p+/ =!"#$%. tDeCheck1tDeCheck1tDeCheck1DText2Enter applicant's name.DEnter applicant's name.DEnter mailing address.DEnter mailing address.DEnter location address.DEnter location address.DEnter Web site address.DEnter agency name.DEnter agent's name.DEnter address.DEnter address.DEnter e-mail address.DEnter phone number.R$$If!vh#v#v:V lV t655ytzDM/d/yyEnter date (mm/dd/yy).DM/d/yyEnter date (mm/dd/yy).tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1DIdentify other/applicant.D 0"Enter number of years in business.D 0Enter number of years.tDeCheck6tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1hDetDeCheck1tDeCheck1DiText9Describe other.$$If!vh#v#v:V l t0P(655/ / / / ayt|D Enter inspection contact person.DEnter telephone number.tDeCheck2tDeCheck2tDeCheck2tDeCheck2DText10(Please explain and advise where insured.$$If!vh#v':V lX t065'/ aytetDeCheck7tDeCheck8D-Text12&Enter name(s) and/or policy 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