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ConferenceGuard Application

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Association/Organization Information
Dates

Policy effective dates requested: (maximum 12 months)

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*Must be at least 14 days prior to the first start date for all scheduled Events.

Address
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Primary Event
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Please Note: Coverage is NOT available.
2)
Please provide the projected revenue by category for your Primary Event
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THE FOLLOWING QUESTIONS ARE ONLY APPLICABLE FOR NON‐APPEARANCE OF PRINCIPLE SPEAKER COVERAGE
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Please click and skip the questions on the current page.

Keynote Speaker


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Speaker 2

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Speaker 3

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Speaker 4

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Please attach copies of following documents.
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IT IS AGREED THAT IF THERE IS KNOWLEDGE OR INFORMATION OF SUCH FACTS, CIRCUMSTANCES, OR SITUATIONS AFTER THE COMPLETION DATE OF THIS APPLICATION, AND BEFORE THE DATE INSURANCE COMMENCES FOR THE EVENT, YOU MUST DISCLOSE THE CIRCUMSTANCES TO THE COMPANY IMMEDIATELY, AS THIS MAY AFFECT INSURANCE.

Person designated to receive all notices from the Company or its authorized representative concerning the coverage:
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Please read the Fraud Statement pertaining to the state in which the Association or Organization is located.



FRAUD STATEMENT

STANDARD NOTICE TO ALL APPLICANTS (other than applicants in states listed below): Any person who knowingly presents false information in an application for insurance or knowingly presents a false or fraudulent claim for payment of a loss or benefit is guilty of insurance fraud, which is a crime, and may be subject to fines and confinement in prison.

State laws require us to include the following fraud notices:

Notice to the Applicant(s): 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 may subject person to criminal and civil penalties.
Colorado 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 with regard to a settlement or award payable frominsurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
District of
Columbia
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.
Florida Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or any application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Kentucky Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing 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.
Maine 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.
Minnesota A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
New Jersey Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.
New York Any person who knowingly and with intents 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 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.
Ohio 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 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 Any person who knowingly and with intent to defraud or solicit another to defraud an insurer: (1) By submitting and application or (2) by filing a claim containing false statement as to any material fact may be violating state law.
Pennsylvania 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.
Tennessee 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.
Texas If a life, health and accident insurer provides a claim form for a person to use to make a claim, that forms just contain the following statement or a substantially similar statement “any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
Virginia 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.
West Virginia Any person who knowingly presents a false or fraudulent claim for payment or a loose 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.

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ALL QUOTATIONS ARE SUBJECT TO THE RECEIPT AND ACCEPTABLE REVIEW OF THE APPLICATION AND OTHER UNDERWRITING INFORMATION BY THE UNDERWRITER.

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(By typing your name in this box and clicking submit you are accepting the terms of this application.)

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