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Event Insurance Fraud Statement

I declare, under penalty of perjury, that I am not aware of any circumstances which may result in a loss under this policy, and to the best of my knowledge and belief, the information provided above is true and I have not withheld any material facts. I understand that any false information may void coverage under this policy. (Note: A material fact is one that is likely to influence the underwriter’s assessment of pricing and terms or acceptance of this application.

I agree that should a contract of insurance be concluded, this application and the statements made herein shall form the basis of the contract.

Specific information for residents in LA, ME, NJ, OH, PA, TN, and VA: Any person who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.