Welcome to the American Alpine Club Life Insurance Program!  We stand ready to assist AAC members in their search for affordable "climbing friendly" life insurance plans.  

Instead of taking a "one size fits all" approach, we work closely with our various insurance company partners to create a custom policy that suits your needs.  In order to do so, we need to get to know you and learn more about your current health and climbing activities.  Therefore, we ask that you complete the form below. 

Thank you for this opportunity to be of service!

Name *
Name
Phone *
Phone
Address *
Address
Gender *
Current Health Status *
Tobacco Use
Are you a current AAC member? *
Desired length of coverage? *
Type(s) of climbing? *
click all that apply
Any climbs in the past 24 months above 13,000 feet (4,000 meters)? If yes, provide details including total number of climbs, heights attained and safety equipment used. Please also include the country/region and the name of the peak(s) and route(s) and, if applicable, include the YDS grade/numerical difficulty rating (should correspond with your answers above) *
Please check any additional activities you have done in the past 24 months or intend to do in the next 24 months *
please check all that apply
Interested in other products?
Please click all that apply

For More Information on Mountain Climbers Insurance.

 

accidental death

Disability & Life Insurance
Protecting your most valuable asset... your ability to earn a living!

If you would like to receive USA Cycling Member discounted Disability and/or Life Insurance quotes, please complete the following form. 

Name *
Name
Phone *
Phone
Address
Address
Date of Birth *
Date of Birth
Are you a USA Cycling Member? *
Gender *
Current Health *
Tobacco Use *
Which products are you interested in? *
Check all that apply
Please let us know if you would like a quote for any additional products
check all that apply

* INSURANCE PRODUCTS ARE PROVIDED BY LICENSED REPRESENTATIVES WITH NICHOLAS HILL GROUP, INC.  PLANS ARE SUBJECT TO FULL UNDERWRITING AND INCLUDE CERTAIN EXCLUSIONS AND LIMITATIONS.  NOT ALL PLANS ARE AVAILABLE IN ALL STATES.  PLEASE CONTACT US TO LEARN IF PLANS ARE AVAILABLE IN YOUR AREA.

American Quarter Horse Association Member Life Insurance Quote Request Form

American Quarter Horse Association
Member Life Insurance Quote Request Form

Please complete the following form to receive your no obligation life insurance quote(s). 

Name *
Name
Phone *
Phone
Address
Address
Date of Birth *
Date of Birth
Gender *
Current Health Status *
Tobacco Use *
Are you a current AQHA Member? *
Which product are you interested in? *
I am also interested in the following products
check all that apply

* INSURANCE PRODUCTS ARE PROVIDED BY LICENSED REPRESENTATIVES WITH NICHOLAS HILL GROUP, INC.  PLANS ARE SUBJECT TO FULL UNDERWRITING AND INCLUDE CERTAIN EXCLUSIONS AND LIMITATIONS.  NOT ALL PLANS ARE AVAILABLE IN ALL STATES.  PLEASE CONTACT US TO LEARN IF PLANS ARE AVAILABLE IN YOUR AREA.

Life Insurance Quote Request Form

Name *
Name
Phone *
Phone
Address
Address
Date of Birth *
Date of Birth
Gender *
If yes, please tell us which association you are a member of below
Current Health Status *
Tobacco Use *
Which product are you interested in? *
I am also interested in the following products
check all that apply

* INSURANCE PRODUCTS ARE PROVIDED BY LICENSED REPRESENTATIVES WITH NICHOLAS HILL GROUP, INC.  PLANS ARE SUBJECT TO FULL UNDERWRITING AND INCLUDE CERTAIN EXCLUSIONS AND LIMITATIONS.  NOT ALL PLANS ARE AVAILABLE IN ALL STATES.  PLEASE CONTACT US TO LEARN IF PLANS ARE AVAILABLE IN YOUR AREA.

 

Long-Term Care & Medicare Supplement Insurance Quote Request Form

Name *
Name
Phone *
Phone
Address
Address
Date of Birth *
Date of Birth
Gender *
If yes, please tell us which association you are a member of below
Current Health Status *
Tobacco Use *
I am also interested in the following products
check all that apply

* INSURANCE PRODUCTS ARE PROVIDED BY LICENSED REPRESENTATIVES WITH NICHOLAS HILL GROUP, INC.  PLANS ARE SUBJECT TO FULL UNDERWRITING AND INCLUDE CERTAIN EXCLUSIONS AND LIMITATIONS.  NOT ALL PLANS ARE AVAILABLE IN ALL STATES.  PLEASE CONTACT US TO LEARN IF PLANS ARE AVAILABLE IN YOUR AREA.

Long-Term Care Insurance Quote Request Form

Name *
Name
Phone *
Phone
Address
Address
Date of Birth *
Date of Birth
Gender *
If yes, please tell us which association you are a member of below
Current Health Status *
Tobacco Use *
I am also interested in the following products
check all that apply

* insurance products are provided by licensed representatives with nicholas hill group, inc.  PLANS ARE SUBJECT TO FULL UNDERWRITING and include certain exclusions and limitations.  NOT ALL PLANS ARE AVAILABLE IN ALL STATES.  PLEASE CONTACT US TO LEARN IF PLANS ARE AVAILABLE IN YOUR AREA.

Do I Need Disability Insurance?

There is a 25% chance a worker will need this type of insurance in his or her career. Why take the risk? With Nicholas Hill Group’s disability insurance options, which are provided by highly rated insurance company partners, you can potentially have 40 to 65% of your income covered. This type of insurance is becoming more and more cost effective at the available price points.

If you have a family, this type of insurance will make sure you can pay bills, buy groceries, make car and mortgage payments, and sometimes even continue contributing to you and your children’s future investments.

Click here for more information.

Disability Insurance Quote Request Form

Name *
Name
Phone *
Phone
Address
Address
Date of Birth *
Date of Birth
Gender *
If yes, please tell us which association you are a member of below
Current Health Status *
Tobacco Use *
Which product are you interested in *
I am also interested in the following products
check all that apply

* INSURANCE PRODUCTS ARE PROVIDED BY LICENSED REPRESENTATIVES WITH NICHOLAS HILL GROUP, INC.  PLANS ARE SUBJECT TO FULL UNDERWRITING AND INCLUDE CERTAIN EXCLUSIONS AND LIMITATIONS.  NOT ALL PLANS ARE AVAILABLE IN ALL STATES.  PLEASE CONTACT US TO LEARN IF PLANS ARE AVAILABLE IN YOUR AREA.

Dental and/or Vision Insurance Quote Request Form

Name *
Name
Phone *
Phone
Address
Address
Date of Birth *
Date of Birth
Gender *
If yes, please tell us which association you are a member of below
Current Health Status *
Tobacco Use *
Which product are you interested in?
I am also interested in the following products
check all that apply

* INSURANCE PRODUCTS ARE PROVIDED BY LICENSED REPRESENTATIVES WITH NICHOLAS HILL GROUP, INC.  PLANS ARE SUBJECT TO FULL UNDERWRITING AND INCLUDE CERTAIN EXCLUSIONS AND LIMITATIONS.  NOT ALL PLANS ARE AVAILABLE IN ALL STATES.  PLEASE CONTACT US TO LEARN IF PLANS ARE AVAILABLE IN YOUR AREA.

AMERICAN ALPINE CLUB MEMBERCLIMBING EQUIPMENT INSURANCE

AMERICAN ALPINE CLUB MEMBERCLIMBING EQUIPMENT INSURANCE

Please complete the following form to apply for your Equipment / Gear Insurance Policy...

Name *
Name

Mountain Bike Club/Chapter Directors and Officers Liability Insurance (D&O Insurance)

APPLICATION FOR THE HARTFORD NON-PROFIT CHOICESM (D&O/EPL COVERAGE PARTS ONLY – MISCELLANEOUS) 
NOTICE: THE LIABILITY COVERAGE PARTS SCHEDULED IN ITEM 5 OF THE DECLARATIONS PROVIDE CLAIMS MADE COVERAGE.  EXCEPT AS OTHERWISE SPECIFIED HEREIN, COVERAGE APPLIES ONLY TO A CLAIM FIRST MADE AGAINST THE INSUREDS DURING THE POLICY PERIOD OR ANY EXTENDED REPORTING PERIOD, IF APPLICABLE AND PAYMENT OF DEFENSE COSTS REDUCE THE LIMIT OF LIABILITY.  NOTICE OF A CLAIM MUST BE GIVEN TO THE INSURER AS SOON AS PRACTICABLE, AFTER A NOTICE MANAGER BECOMES AWARE OF SUCH CLAIM, BUT IN NO EVENT LATER THAN NINETY (90) CALENDAR DAYS AFTER THE TERMINATION OF THE POLICY PERIOD, OR ANY EXTENDED REPORTING PERIOD.  PLEASE READ THE POLICY CAREFULLY AND DISCUSS THE COVERAGE WITH YOUR INSURANCE AGENT OR BROKER. 

Address *
Address
Only available to clubs and chapters located in the United States. Please list USA in the Country field.
Date of Incorporation
Date of Incorporation
Contact Person *
Contact Person
Phone *
Phone
Coverage Questions
Proposed Effective Date *
Proposed Effective Date
Directors & Officers Liability (D&O) / Employment Practices Liability Insurance
If desired, please check the box below and provide your desired D&O insurance limit
ORGANIZATION INFORMATION
(If Revenue is greater than $1,000,000, please provide a copy of the most recent CPA Audit or IRS Form 990)
$
$
Is the Organization involved in any lending, credit or collection activities? *
If yes, please provide details below
Does the organization have an annual or bi-annual meeting, convention or similar gathering? *
Is the Organization currently or has it at any time over the last year been in breach or violation of any debt covenant or loan agreement or any other material contractual obligation? *
If yes, please provide details below
Has the Organization experienced within the past 2 years or does the Organization expect any of the following events within the next 2 years:
Any financial reorganization or filing for bankruptcy? *
If yes, please provide details below
Any downsizing, layoffs, reduction in force, or office closings? *
If yes, please provide details below
Does the organization maintain:
An audit committee? *
An investment committee? *
An executive compensation committee? *
Please list the following information for the current 12 months (if “None”, please indicate):
Enter "0" if none
Does the Organization maintain and distribute an employee handbook? *
Does the Organization have a Human Resources Department? *
Prior Knowledge
Does anyone for whom insurance is being applied have any knowledge or information of any error, misstatement, misleading statement, act omission, neglect, breach of duty or other matter that may give rise to a claim that may fall within the scope of coverage of the proposed insurance? *
If yes, please provide details below
IT IS AGREED THAT IF SUCH KNOWLEDGE OR INFORMATION EXISTS, ANY CLAIM BASED ON, ARISING FROM, OR IN ANY WAY RELATING TO SUCH ERROR, MISSTATEMENT, MISLEADING STATEMENT, ACT, OMISSION, NEGLECT, BREACH OFDUTY OR OTHER MATTER OF WHICH THERE IS KNOWLEDGE OR INFORMATION SHALL BE EXCLUDED FROM COVERAGE UNDER THE INSURANCE BEING APPLIED FOR. *
Loss History
Within the last 3 years, has the applicant, its directors, officers and/or any other proposed insured person or organization received any complaint, suit, inquiry or notice of hearing from any state or federal body, or any other party? *
If yes, please provide details below.
Has any Insurer cancelled or refused to renew any Directors and Officers, Employment Practices, Fiduciary Liability, Crime/Fidelity, or similar insurance within the past 3 years? *
If yes, please provide details below.
IT IS AGREED THAT IF ANY SUCH COMPLAINTS, SUITS, INQUIRIES OR NOTICES EXIST, ANY CLAIM BASED UPON, ARISING FROM OR IN ANY WAY RELATED TO SUCH MATTERS SHALL BE EXCLUDED FROM THE INSURANCE BEING APPLIED FOR. THE INFORMATION PROVIDED IN THIS APPLICATION IS FOR UNDERWRITING PURPOSES ONLY AND DOES NOT CONSTITUTE NOTICE TO THE COMPANY OF A CLAIM OR POTENTIAL CLAIM UNDER ANY POLICY. IF YOU INTEND TO NOTICE A CLAIM OR POTENTIAL CLAIM FOR POSSIBLE COVERAGE, PLEASE COMPLY WITH THE NOTICE OF CLAIM CONDITIONS/PROVISIONS FOUND IN YOUR POLICY, BY SENDING WRITTEN NOTICE OF SUCH TO: (Insert the address and phone number of the local The Hartford office.)
California Notice: The Hartford may charge a fee if this bond or policy is cancelled before the end of its term. The fee can range between 5% to 100% of the pro rata unearned premium. Please refer to the terms and conditions stated in the policy or bond. This notice does not apply to cancellations initiated by The Hartford.
FRAUD WARNING STATEMENTS ALABAMA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO RESTITUTION FINES OR CONFINEMENT IN PRISON, OR ANY COMBINATION THEREOF. ARKANSAS APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. COLORADO APPLICANTS: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE, AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICY HOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICY HOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES. DISTRICT OF COLUMBIA APPLICANTS: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT." FLORIDA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. HAWAII APPLICANTS: FOR YOUR PROTECTION, HAWAII LAW REQUIRES YOU TO BE INFORMED THAT PRESENTING A FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT IS A CRIME PUNISHABLE BY FINES OR IMPRISONMENT, OR BOTH. KANSAS APPLICANTS: A " FRAUDULENT INSURANCE ACT " MEANS AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER OR ANY AGENT THEREOF, ANY WRITTEN STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO. KENTUCKY APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME. LOUISIANA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. MAINE APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS. MARYLAND APPLICANTS: ANY PERSON WHO KNOWINGLY OR WILLFULLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY OR WILLFULLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. NEW JERSEY APPLICANTS: ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES. NEW MEXICO APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES. OHIO APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD. OKLAHOMA APPLICANTS: WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY. OREGON APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD OR SOLICIT ANOTHER TO DEFRAUD AN INSURER: (1) BY SUBMITTING AN APPLICATION OR; (2) FILING A CLAIM CONTAINING A FALSE STATEMENT AS TO ANY MATERIAL FACT MAY BE VIOLATING STATE LAW. PENNSYLVANIA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. PUERTO RICO APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD AN INSURANCE COMPANY PRESENTS FALSE INFORMATION IN AN INSURANCE APPLICATION, OR PRESENTS, HELPS, OR CAUSES THE PRESENTATION OF A FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS OR ANY OTHER BENEFIT, OR PRESENTS MORE THAN ONE CLAIM FOR THE SAME DAMAGE OR LOSS, SHALL INCUR A FELONY AND, UPON CONVICTION, SHALL BE SANCTIONED FOR EACH VIOLATION WITH THE PENALTY OF A FINE OF NOT LESS THAN FIVE THOUSAND (5,000) DOLLARS AND NOT MORE THAN TEN THOUSAND (10,000) DOLLARS, OR A FIXED TERM OF IMPRISONMENT FOR THREE (3) YEARS, OR BOTH PENALTIES. IF AGGRAVATED CIRCUMSTANCES PREVAIL, THE FIXED ESTABLISHED IMPRISONMENT MAY BE INCREASED TO A MAXIMUM OF FIVE (5) YEARS; IF EXTENUATING CIRCUMSTANCES PREVAIL, IT MAY BE REDUCED TO A MINIMUM OF TWO (2) YEARS. RHODE ISLAND APPLICANTS: “ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.” TENNESSEE APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS. VIRGINIA APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS. VERMONT APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN APPLICATION FOR INSURANCE MAY BE GUILTY OF A CRIMINAL OFFENSE AND SUBJECT TO PENALTIES UNDER STATE LAW. WASHINGTON APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES, AND DENIAL OF INSURANCE BENEFITS." WEST VIRGINIA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. NEW YORK APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION." THE UNDERSIGNED AUTHORIZED OFFICER OF THE APPLICANT DECLARES THAT THE STATEMENTS SET FORTH HEREIN ARE TRUE. THE UNDERSIGNED AUTHORIZED OFFICER AGREES THAT IF THE INFORMATION SUPPLIED ON THIS APPLICATION CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE EFFECTIVE DATE OF THE INSURANCE, HE/SHE (UNDERSIGNED) WILL, IN ORDER FOR THE INFORMATION TO BE ACCURATE ON THE EFFECTIVE DATE OF THE INSURANCE, IMMEDIATELY NOTIFY THE INSURER OF SUCH CHANGES, AND THE INSURER MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS AND/OR AUTHORIZATIONS OR AGREEMENTS TO BIND THE INSURANCE. THE “EFFECTIVE DATE” IS THE DATE THE COVERAGE IS BOUND OR THE FIRST DAY OF THE CURRENT POLICY PERIOD, WHICHEVER IS LATER. SIGNING OF THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE INSURER TO COMPLETE THE INSURANCE, BUT IT IS AGREED THAT THIS APPLICATION SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED AND IT WILL BE ATTACHED TO AND BECOME A PART OF THE POLICY. ALL WRITTEN STATEMENTS AND MATERIALS FURNISHED TO THE INSURER IN CONJUNCTION WITH THIS APPLICATION ARE HEREBY INCORPORATED BY REFERENCE INTO THIS APPLICATION AND MADE A PART HEREOF. THIS APPLICATION MUST BE SIGNED BY THE CHAIRMAN OF THE BOARD, CHIEF EXECUTIVE OFFICER OR THE PRESIDENT OF THE ORGANIZATION.
Electronic Signature *
Electronic Signature
Please type your name if you agree to the above terms and attest to the above answers and would like to submit your application electronically.
Address 1 *
Address 1
Date *
Date