Terms & Conditions. Completion of this enrollment form confirms your desire to obtain insurance through the Sports, Leisure and Entertainment Risk Purchasing Group or the WellnessPRO Purchasing Group. The submission of this enrollment form and/or acceptance of payment does not guarantee coverage. Certain operations are not eligible for coverage under this program. PRO Insurance Managers reserves the right to decline any request for coverage. You realize that any false, or inaccurate statement or misrepresentation in the enrollment form may result in claim denial or contract rescission. Any person who injures, defrauds, or deceives 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. You understand that the plan applied for will not pay benefits for any expenses incurred on account of any claim before the effective date or for the products/services that you sell/market. You further acknowledge that you have reviewed all information provided with this enrollment form and understand the exclusions that apply, as well as the activities and operations for which coverage is not provided.
I understand the plan hereby applied for will not be considered in force until a policy or certificate is issued and full payment of applicable charges and fees (fee portion of cost – option #1 = $130 to $145; option #2 = $252 to $267; option #3 = $217 to $232; option #4 = $383 to $398; certain insurance company charges include excess and surplus lines fees – call PRO for specific fees by state; a 3% processing fee may be charged in addition to the fees shown) has been received and other conditions remain as described in this application. Any charges and fees charged under this program are fully earned and are not refundable. No representation except by PRO Insurance Managers, Inc. or the company are binding. No other person has the authority to issue or change coverage or the effective date of coverage.
Warranty & Electronic Disclosure and Consent
Electronic Signature Disclosure and Consent
The Electronic Signatures in Global and National Commerce Act (15 U.S.C. subsection 7001, et seq.) provides that a signature, contract or other record may not be denied legal effect, validity or enforceability solely because it is in electronic form or because an electronic signature was used in a transaction.
PRO lnsurance Managers, Inc. (PRO), whelher on its own behalf and/or on behalf of an insurer and/or third parties, may utilize the internet, email, cloud services, digital storage, digital media or similar electronic means to transmit Policy Documents to its clients. This Agreement informs you of your rights when we are delivering and you are receiving such documents from us electronically.
By agreeing to proceed with this transaction, you acknowledge and consent to the following:
1. I hereby voluntarily consent to proceeding with this transaction, and all subsequent actions related to this transaction, electronically.
2. I understand that further documents relating to this insurance purchased through PRO, including but not limited to correspondence, communications, confirmations, requests for premium payments and policy documents, may, to the extent permitted by law, be transmitted by electronic means to me, including by e-mail sent to the e-mail address I have provided as part of this transaction and/or my on-line registration. I consent to such documents being provided to me electronically.
3. Notwithstanding paragraph 2, any notice of cancellation shall be sent to me by mailing to the address I have provided as part of my registration and/or application for insurance, or to such other address for which I have provided notice pursuant to the terms of the policy.
4. Any change or revision to the e-mail address or other electronic contact information which I have provided as part of this transaction and/or my on-line registration process shall be requested by me by logging onto this website, or by mailing a written notice to: PRO lnsurance Managers, Inc., P.O. Box 24427, Overland Park, KS 66283-4427,
5. I understand that I have the right to obtain a paper copy of any electronic record provided to me pursuant to thls transaction or any subsequent transaction involving my coverage by mailing a written request to the address provided in paragraph 4.
6. ln order to access the electronic records provided, the following hardware and software are required: (a) a personal computer or other device through which lnternet access is available, (b) an lnternet connection, (c)an e-mail account with an lntemet service provider, and (d) Adobe Acrobat Reader.
7. I understand that I have the right and option to withdraw my consent to the receipt of further electronic documents at any time, by mailing a written request to the address provided in paragraph 4. By withdrawing my consent to electronic delivery of documents I understand that I will receive a paper copy of future policy documentation.
8. lnformation relating to this transaction is subject to the terms of our privacy statement, a copy of which is provided atwww.pro4.us.
Warranty and Disclosure Statement: I understand that the insurance company, in determining whether to provide insurance coverage, will rely on the information contained in this form and all other information being submitted. I hereby warrant, represent and confirm that, to thd best of my knowledge, all information provided is complete, true and correct.
I am aware that the insurance company expects accurate reporting for my premium calculation. I understand that my books and records may be examined or audited by the insurance company at any time during the coverage period and up to three years thereafter. lntentional misrepresentation or misreporting may jeopardize coverage. We reserve the right to decline/void any ineligible coverage.
I further acknowledge that, I have reviewed all infomation provided with this enrollment form and understand the exclusions which apply, as well as the activities and operations for which coverage is not provided.
|GENERAL FRAUD STATEMENT
|Applicable in AL, AR, DC, LA, MD, NM, RI and WV Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or 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. *Applies in MD Only.
Applicable in CO 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.
Applicable in FL and OK 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)*. *Applies in FL Only.
Applicable in KS 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, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or 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 falseinformation concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.
Applicable in KY, NY, OH and PA 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 tocriminal and civil penalties* (not to exceed five thousand dollars and the stated value of the claim for each such violation)*. *Applies in NY Only.
Applicable in ME, TN, VA and WA 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 and denial of insurance benefits. *Applies in ME Only.
Applicable in NJ Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
Applicable in OR Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law.
I warrant and represent that by clicking “I Agree” that I authorize PRO Insurance to charge my payment for the coverage ordered and verify and affirm any information I’ve completed above and that I understand and agree to all of the foregoing.
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