IMPORTANT NOTICE
Any person who knowingly and with intent to defraud any insurance company or another 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 the person to criminal and (NY: substantial) civil penalties. (Not applicable in CO, DC, FL, HI, MA, NE, OH, OK, OR, VT or WA; in LA, ME, TN and VA, insurance benefits may also be denied.)
In Colorado, it is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement of award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
In the District of Columbia, WARNING: 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.
In Florida, any person who knowingly and with intent to injure, defraud, or deceive any insurer, files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
In Hawaii, for your protection, the 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.
In Kansas, any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal
insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act.
In Massachusetts, Nebraska, Oregon and Vermont, any person who knowingly and with intent to defraud any insurance company or another 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, may be committing a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties.
In Minnesota, any person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
In Ohio, any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deception statement is guilty of insurance fraud.
In Oklahoma, WARNING: 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.
In 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.
Authorization & Signature Section:
By my signature below, I, the undersigned, also authorize the motor carrier, any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance company or any other organization, institution or person that has any records, including any medical records, to furnish such information or copies of records to Atlantic Specialty Insurance Company, the motor carrier or the motor carrier’s designee. A photographic copy of this authorization shall be as valid as the original.
IF THE INFORMATION PROVIDED IN THIS FORM IS FRAUDULENT, THE INSURER HAS THE RIGHT TO RETURN PREMIUM AND CANCEL COVERAGE.
In order to verify the information provided in this form, I, the undersigned, give the Insurer authority to examine the records that are maintained by the motor carrier.
By signing below, I affirm knowledge of and adherence to current D.O.T. safety regulations, and hereby apply for insurance with respect to the coverage stated on this Enrollment Form.
By my signature below, I also acknowledge the following statements are true. Please read them carefully.
1. I understand that the giving of any inaccurate, false, or misleading information on this application will result in rejectionof this application and the denial of benefits under any and all insurance coverages for which I have applied.
2. I authorize the release to AB all insurance documents related to me or my equipment and current Motor Vehicle Report.
3. I understand the statements and information provided herein are being used by AB to secure insurance coverage on mybehalf. The statements and covenants made by me will be incorporated in and made a part of each respective insurancepolicy by this reference when issued.
4. I acknowledge that this application and the information contained herein are the property of AB and may be used by AB,as they deem necessary in the conduct of their business.
5. I understand that no coverage will be in effect until approved by AB and the insurance carrier.
6. Limited Power of Attorney: the undersigned hereby makes, constitutes, and appoints AB as the undersigned’s true andlawful attorney in fact for and in the undersigned’s name to execute and cancel all coverages through AB.
7. We do not accept debit cards, and we will impose a surcharge when paying by credit card. This surcharge may fluctuate;however, it will never exceed 4% of the balance due or the cost of our acceptance. There is not a surcharge on paymentsset up by ACH.
8. I understand these policies are for commercial units contracting with FedEx used to deliver packages and on the ScheduleB of my Independent Service Provider Agreement.
9. I acknowledge and agree that Avant may issue and deliver Policies in an electronic format.
10. I authorize to receive documents electronically.
Note: Insurance coverage cannot be put into effect until we receive all completed, signed forms and payment.
