ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY AGENT: OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
Signing this form does not bind the applicant or company to this insurance, but it is agreed that this form shall be the basis of the contract should this policy be issued.
This form may not be duplicated or reproduced - in whole or in part - without the expressed written consent of Hummel Group, Inc.