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Form G-4190-0 (ED. 11/22)Page 1 of 1 © 2022, The Hartford FRAUD NOTICE The following statement is added to the policy: CALIFORNIA NOTICE:For your protection California law requires the following to appear on this form:Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. COLORADO NOTICE: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 policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder 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. NEW YORK NOTICE: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,and any person who,in connection with such application or claim,knowingly makes or knowingly assists,abets,solicits or conspires with another to make a false report of the theft,destruction,damage or conversion of any motor vehicle to a law enforcement agency,the department of motor vehicles or an insurance company,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 value of the subject motor vehicle or the stated value of the claim for each such violation. PENNSYLVANIA NOTICE:Any person who knowingly and with intent to injure or defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false,incomplete,or misleading 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,including imprisonment for up to seven years and payment of a fine of up to $15,000. Docusign Envelope ID: 9DF92A24-B534-85BA-8088-342315DF1839