Disability Claim Form

I HEREBY DECLARE that I am the person assured under this policy or the policyholder’s appointed representative and that the accident and resultant disablement was not due in any way whatsoever to indulgence in alcoholic liquor or to the use of drugs of any kind and that the stated disablement did not exist prior to the policy commencement date.

I FURTHER DECLARE THAT THE ABOVE REPLIES ARE TRUE IN EVERY PARTICULAR and agreed that if any FALSE statement was made by me or if withheld any material fact in connection with my claim for compensation my right to compensation under the above policy shall be FORFEITED.

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.)