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U-GU-1147-A (01/14)
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<br />Fraud Warnings Disclosure
<br />TO BE ATTACHED TO AND FORM PART OF THE APPLICATION. IF FRAUD WARNINGS ARE INCLUDED IN THE
<br />APPLICATION TO WHICH THIS IS ATTACHED, THIS DISCLOSURE REPLACES THOSE WARNINGS.
<br />Any person who knowingly and with intent to defraud any insurance company or another 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 the
<br />person to criminal and civil penalties. (Not applicable in AL, AR, CO, DC, FL, KS, KY, LA, MD, ME, NJ, NM, NY, OH, OK,
<br />OR, PA, PR, RI, TN, TX, VA, VT, WA, and WV.)
<br />In Arkansas, Louisiana, Rhode Island, or West Virginia: Any person who knowingly presents a false or fraudulent
<br />claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a
<br />crime and may be subject to fines and confinement in prison.
<br />In Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who
<br />knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution,
<br />fines or confinement in prison, or any combination thereof.
<br />In Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance
<br />company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines,
<br />denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly
<br />provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or
<br />attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds
<br />shall be reported to the Colorado division of insurance within the department of regulatory agencies.
<br />In District of Columbia: Warning: It is a crime to provide false or misleading information to an insurer for the purpose of
<br />defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny
<br />insurance benefits if false information materially related to a claim was provided by the applicant.
<br />In Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim
<br />or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
<br />In Kansas: Any person who, knowingly and with intent to defraud, presents, causes to be presented or
<br />prepares with knowledge or belief that it will be presented to an insurer, purported insurer, or to or by a broker
<br />or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the
<br />rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit
<br />pursuant to an insurance policy for commercial or personal insurance which such person knows to contain
<br />materially false information concerning any fact material thereto; or conceals, for the purpose of misleading,
<br />information concerning any fact material thereto, commits a fraudulent insurance act and may be subject to
<br />criminal and/or civil fines or penalties.
<br />In Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an
<br />application for insurance 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.
<br />In Maine, Tennessee, Virginia, or Washington: It is a crime to knowingly provide false, incomplete or misleading
<br />information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment,
<br />fines or a denial of insurance benefits.
<br />DocuSign Envelope ID: 2D437FD3-F8AA-487E-900D-AD3E72792492
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