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DocuSign Envelope ID: EE765B38-37EF-4402-B4E9-8B82F98E2EE8 <br /> For applicants in Florida: <br /> Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an <br /> application containing any false,incomplete,or misleading information is guilty of a felony of the third degree. <br /> For applicants in Kentucky,New Mexico,Ohio,and Pennsylvania: <br /> Any person who knowingly and with intent to defraud any insurance company or other person files an application for <br /> insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, <br /> information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such <br /> person to criminal and civil penalties. <br /> For applicants in Maine,Tennessee and Virginia: <br /> It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of <br /> defrauding the company.Penalties may include imprisonment,fines,or a denial of insurance benefits. <br /> For applicants in New Jersey: <br /> Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal <br /> and civil penalties. <br /> For applicants in all other states: <br /> If is a crime to knowingly provided false, incomplete, or misleading information to an insurance company for the purpose of <br /> defrauding the company.Penalties may include imprisonment,fines,or a denial of insurance benefits. <br /> UHIAPP(12/01) <br />