Completion of this enrollment form confirms your desire to obtain insurance through the Sports, Leisure and Entertainment Risk Purchasing Group or 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 by 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. 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 has been received and other conditions remain as described in this application. The charges and fees charged under this program are fully earned and are not refundable, a 3% credit/debit card offset fee is charged in addition to the fees shown. 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.
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 false information 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 to criminal 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.
When you may be required by a tradeshow, fair, meeting facility, convention, etc. to name them as an “Additional Insured” onto your General Liability coverage, we can help, just complete the request form below and a certificate will be issued and emailed to you.
You must already be enrolled under the General Liability coverage offered through PRO Insurance to apply for the Additional Insured certificate. If you are not already enrolled, please Click Here. No certificates will be issued unless you have inforce coverage.
DISCLAIMER: Products and services referenced herein may not be available in all jurisdictions. The information and descriptions contained herein are not intended to be complete descriptions of all terms, exclusions and conditions applicable to the products and services, but are provided solely for general informational purposes. Never cancel coverage until advised that replacement coverage is effective.
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