Note: By submitting this form you understand that no coverage is bound until you receive written notice. You also agree to release us from any liability if this information is accidentally viewed by unauthorized persons. We will only use this information for insurance quoting purposes and not distribute to other parties.
Notice of Insurance Information Practices: Personal information about you, including information from a credit report and loss history may be collected from persons other than you in connection with this application for insurance and subsequent policy renewals. You have the right to review your personal information in our files and can request correction of any inaccuracies. Such information as well as other personal and privileged information collected by us or our agents may in certain circumstances be disclosed to third parties without your authorization to assist in servicing your account. A more detailed description of your rights and our practices regarding such information can be accessed by contacting your agent or broker and asking for additional details about our information and disclosure practices.
Any person who knowingly and with intent to defraud any insurance company or another 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 the person to criminal and (NY: substantial) civil penalties. (Not applicable in CO, HI, NE, OH, OK, OR, or VT; in DC, LA, ME, TN, VA and WA, insurance benefits may also be denied).
