You, the undersigned Defendant (“Defendant” or “you”), hereby represent and warrant that the following declarations made and answers given are true, complete and correct and are made for the purpose of inducing Bankers Insurance Company (“Surety”) to issue, or cause to be issued, bail bond(s) or undertaking(s) for you (singularly or collectively the “Bond”), using power of attorney number(s) (if known)

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ALABAMA RESIDENTS
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or
any combination thereof.
ARKANSAS RESIDENTS
Any person who knowingly presents a false or fraudulent claim for payment for 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.
FLORIDA RESIDENTS
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.
LOUISIANA, RHODE ISLAND & WEST VIRGINIA RESIDENTS
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.
MAINE, TENNESSEE, VIRGINIA & WASHINGTON RESIDENTS
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.
MARYLAND RESIDENTS
Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who 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.
NEW JERSEY RESIDENTS
Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and
civil penalties.
NEW MEXICO RESIDENTS
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.
NEW YORK RESIDENTS
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 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 RESIDENTS
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 RESIDENTS
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.
PENNSYLVANIA RESIDENTS
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 criminal and civil
penalties.