Note to 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 material fact hereto, commits a fraudulent insurance act, which is a
crime and shall be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each
such violation.
This policy is issued by your risk retention group. Your risk retention group may not be subject to all of the insurance laws
and regulations of your State. Insurance insolvency guaranty funds are not available for your risk retention group.
