Property/Casualty Insurance Renewal Survey Multi-State
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- Marylou Whitehead
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1 Property/Casualty Insurance Renewal Survey Multi-State P.O. Box 5670 Cortland, New York Phone (800) Fax: (607) mcneilandcompany.com GENERAL INFORMATION Date of survey: Renewal Date: Date proposal needed: Legal Name of Organization: (Include all organizations that are to be included as insureds including Fire Districts, Fire Companies, Rescue Squads and Auxiliaries) FEIN: Mailing Address: County: Website Address: Phone #: INSURANCE AGENT INFORMATION Producer: CSR or Other Contact Name of Agency: Address: Telephone: Fax: address: Is the account Sub-Brokered? Yes No If yes, please indicate Agency Name and Address: OPERATIONS Number of Employees: Number of Owners/Officers: Describe duties of owners/officers: Have there been any changes in ownership or new companies formed within the past 12 months? Yes No If yes, please describe fully any new companies formed or changes in ownership: Have there been any changes in the operations or exposures of the organization? Yes No If yes, please explain and describe fully: Have you reported any new losses to previous carriers over the past 12 months? Yes No Do you install, service, repair, inspect or test water based suppression/sprinkler systems? Yes No Any within the last 10 years? Yes No Have you or any of your employees received any new or updated training and/or certifications? Yes No RS-FW- MS E d : 1 0 /1 4 M cn e i l & C o., In c. P a g e 1
2 CURRENT COVERAGE AND REQUESTED CHANGES General Liability Information: Class Code/Description Rating Basis Exposure Anticipated Exposure for Next 12 Months Include Waiver of Subrogation? Yes No Include Per Project Aggregate? Yes No Property Information: Premises/Building No. Coverage Value Delete Change Do you have any property that should be added? Yes No If yes, please attach Acords. Business Auto Information: Vehicle No. Year Make Model VIN Physical Damage Delete Change Do you have any vehicles that should be added? Yes No If yes, please attach Accords. Please attach a current list of Drivers including full name, date of birth, date of hire and driver license number. Inland Marine Information: Covered Item Value Deductible Delete Change Do you have any items that should be added? Yes No Item Description Excess Liability Information: Value Limits of Insurance Current Limit Changes Per Occurrence/Annual Aggregate / / Do you currently carry Employers Liability Coverage for all employees? Yes No If yes, please provide the following information: Name of Carrier: Effective Dates: Policy Number: Policy EL Limits: NA-FW- MS E d : 1 0 /1 4 M cn e i l & C o., In c. P a g e 2
3 Application Signatures & State Fraud Statements APPLICABLE IN ALABAMA - ALABAMA FRAUD STATEMENT Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. APPLICABLE IN ALASKA - ALASKA FRAUD STATEMENT A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law. APPLICABLE IN ARIZONA - ARIZONA FRAUD STATEMENT Penalties may include imprisonment, fines or a denial of insurance benefits. APPLICABLE IN ARKANSAS - ARKANSAS FRAUD STATEMENT for insurance is guilty of a crime and may be subject to fines and confinement in prison. APPLICABLE IN CALIFORNIA - CALIFORNIA FRAUD STATEMENT For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. In addition, any person who knowingly makes an application for motor vehicle insurance coverage containing any statement that the applicant resides or is domiciled in this state when, in fact, that applicant resides or is domiciled in a state other than this state, is subject to criminal or civil penalties. APPLICABLE IN COLORADO - COLORADO FRAUD STATEMENT 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 or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. APPLICABLE IN KANSAS - KANSAS FRAUD STATEMENT 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. APPLICABLE IN KENTUCKY - KENTUCKY FRAUD STATEMENT Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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. APPLICABLE IN LOUISIANA - LOUISIANA FRAUD STATEMENT for insurance is guilty of a crime and may be subject to fines and confinement in prison. APPLICABLE IN MAINE - MAINE FRAUD STATEMENT Penalties may include imprisonment, fines or a denial of insurance benefits. APPLICABLE IN MARYLAND - MARYLAND FRAUD STATEMENT Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. APPLICABLE IN MASSACHUSETTS - MASSACHUSETTS FRAUD STATEMENT 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. APPLICABLE IN MICHIGAN - MICHIGAN FRAUD STATEMENT Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to one year and payment of a fine of up to 5,000. APPLICABLE IN MINNESOTA - MINNESOTA FRAUD STATEMENT A person who submits an application or files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. APPLICABLE IN NEBRASKA - NEBRASKA FRAUD STATEMENT 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 may subject the person to criminal and civil penalties. NA-FW- MS E d : 1 0 /1 4 M cn e i l & C o., In c. P a g e 3
4 Application Signatures & State Fraud Statement (Continued) APPLICABLE IN NEW JERSEY - NEW JERSEY FRAUD STATEMENT Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. APPLICABLE IN NEW MEXICO - NEW MEXICO FRAUD STATEMENT for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. APPLICABLE IN NEW YORK - NEW YORK FRAUD STATEMENT Other than Auto: 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 violation. Auto: 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. APPLICABLE IN OHIO - OHIO FRAUD STATEMENT Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. APPLICABLE IN OKLAHOMA - OKLAHOMA FRAUD STATEMENT 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. APPLICABLE IN OREGON - OREGON FRAUD STATEMENT Any person who, knowingly and with intent to defraud or facilitate a fraud against any insurance company or other person, submits an application, or files a claim for insurance containing any false, deceptive, or misleading material information may be guilty of insurance fraud. In order for us to deny a claim on the basis of misstatements, misrepresentations, omissions or concealments on your part, we must show that: A. The misinformation is material to the content of the policy; B. We relied upon the misinformation; and C. The information was either: 1. Material to the risk assumed by us; or 2. Provided fraudulently. For remedies other than the denial of a claim, misstatements, misrepresentations, omissions or concealments on your part must either be fraudulent or material to our interests. With regard to fire insurance, in order to trigger the right to remedy, material misrepresentations must be willful or intentional. Misstatements, misrepresentations, omissions or concealments on your part are not fraudulent unless they are made with the intent to knowingly defraud. APPLICABLE IN PENNSYLVANIA - PENNSYLVANIA FRAUD STATEMENT Other than Auto: 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. Auto: Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and payment of a fine of up to 15,000. APPLICABLE IN TENNESSEE - TENNESSEE FRAUD STATEMENT Penalties include imprisonment, fines and denial of insurance benefits. APPLICABLE IN VERMONT - VERMONT FRAUD STATEMENT Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, may be committing a crime, subjecting the person to criminal and civil penalties. APPLICABLE IN VIRGINIA - VIRGINIA FRAUD STATEMENT Penalties include imprisonment, fines and denial of insurance benefits. APPLICABLE IN WASHINGTON - WASHINGTON FRAUD STATEMENT Penalties include imprisonment, fines, and denial of insurance benefits. NA-FW- MS E d : 1 0 /1 4 M cn e i l & C o., In c. P a g e 4
5 Application Signatures & State Fraud Statement (Continued) GENERAL FRAUD STATEMENT 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 CIVIL PENALTIES. (Not applicable in CO, FL, KS, MA, MN, NE, OH, OK, OR, VT, or WA.) THE UNDERSIGNED REPRESENTS THAT HE/SHE HAS MADE A GOOD FAITH EFFORT TO ASCERTAIN COMPLETE AND ACCURATE ANSWERS TO THE QUESTIONS SET FORTH IN THIS APPLICATION AND THAT THE INFORMATION PROVIDED IN THIS APPLICATION, INCLUDING ANY ATTACHMENTS, IS TRUE, ACCURATE, AND COMPLETE TO THE BEST OF THEIR KNOWLEDGE AND BELIEF. Applicant s Signature Name and title (please print): Insurance Agent s Signature Date: Date: NA-FW- MS E d : 1 0 /1 4 M cn e i l & C o., In c. P a g e 5
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