Purchase Agreement

I agree that all information I have provided is true to the best of my knowledge and belief. I agree to pay the Total Price with the credit card number provided. I am the owner and/or authorized user of this credit card. I understand that any misrepresentations may void my plan/policy and if any statements are knowingly made with the intent to defraud I may be subject to legal action.

Pursuant to Insurance Law § 403(d), all applications for commercial insurance, individual, group or blanket accident and health insurance, including any electronic applications, shall contain a notice in a form approved by the superintendent that clearly states in substance the following: "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."