DISCLAIMERS:

Ariento is not a licensed insurance broker or provider. In submitting this application, the applicant and proposed insured acknowledges that any insurance policies and/or quotes are provided by a third-party and releases Ariento from any liability related to said insurance policies or quotes.

The undersigned is authorized by the applicant and declares that the statements set forth herein and all written statements and materials furnished to the insurer in conjunction with this application are true. Signing of this application does not bind the applicant or the insurer to complete the insurance, but it is agreed that the statements contained in this application, any supplemental applications, and the materials submitted herewith are the basis of the contract should a policy be issued and have been relied upon by the insurer in issuing any policy.

This application and materials submitted with it shall be retained on file with the insurer and shall be deemed attached to and become part of the policy if issued. The insurer is authorized to make any investigation and inquiry in connection with this application as it deems necessary. provided, however, this paragraph does not apply in the states of Utah and Wisconsin.

Note to Utah and Wisconsin residents: all written statements and materials furnished to the insurer in conjunction with this application are made a part hereof provided this application and such materials are attached to the policy at the time of its delivery.

The applicant agrees that if the information supplied on this application changes between the date of this application and the effective date of the insurance, the applicant 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 or authorizations or agreements to bind the insurance.

I have read the foregoing application for insurance including attachment ‘a’ and represent that the responses provided on behalf of the applicant are true and correct.

Warning: any person who, with intent to defraud or knowing that (s)he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.

Notice to 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.”

Notice to 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 policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder 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.”

Notice to district of Columbia applicants: "warning: 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."

Notice to 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 in the third degree.”

Notice to 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.”

Notice to 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."

Notice to 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."

Notice to 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.”

Notice to 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.

The insurer shall not offer an optional extension period for this policy in New Mexico.

Notice to 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.”

Notice to Oklahoma applicants: “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.”

Notice to Oregon 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 may be guilty of insurance fraud which may subject such person to criminal and civil penalties, including but not limited to fines, denial of insurance benefits, civil damages, criminal prosecution and confinement in state prisons.”

Notice to 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.”

Notice to Tennessee, Virginia and 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.”

Notice to 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 claims 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.”

Notice to Wisconsin applicants: as a condition precedent to the right to purchase the optional extension period, the total premium for this policy must have been paid. the right to purchase the optional extension period shall terminate unless written notice together with full payment of the premium for the optional extension period is given to the insurer within thirty (30) days after the effective date of cancellation or non renewal. If such notice and premium payment is not so given to the insurer, there shall be no right to purchase the optional extension period. in the event of the purchase of the optional extension period, the entire premium for the optional extension period shall be deemed earned at its commencement.