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<br />Insured Name: CALDWELL FIRE DEPARTMENT, INC <br />Tuesday, March 11, 2025 Page 23 <br />Any person who knowingly and with intent to defraud any insurance company or other person files an <br />application for insurance or statement of claim containing any materially false information or conceals, for the <br />purpose of misleading, information concerning any fact material thereto, commits a fraudulent act, which is a <br />crime, and may subject such person to criminal and civil penalties. <br />This document is provided to assist in the review and updating of the insured’s exposures. It <br />must not be construed as a coverage document. Actual coverage is provided only by the policy. <br /> By signing, you agree that the information contained in this <br />Renewal Questionnaire is true and accurate to the best of your knowledge. <br />Prepared by (Print): <br />Signature:Date: <br />Title: <br />Docusign Envelope ID: 98CFD7CD-5E86-4B80-B3CD-3F09E1F5D0CF