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A TRUE COPY CERTIFICATION ON LAST PAGE J.R. SMITH, CLERK The undersigned has read the entire Application for Excess Loss Insurance and understandsP#AS insurance requested herein is not in effect until this Application is approved and accepted by the CompanyoJ��t..• Sipe,. Full Legal Name of Applicant: 1ndiarHRtvVr County Board f County Comrl `si S Signature of Authorized Person: R- PrintName: Peter D. O'Bryan Title: Chairman �y;•' + c .\oQ: Date: September 13, 2022 '`�GFgCOUttj1;�''•. Signature of Agent or Broker: Print Name of Agent or Broker: FRAUD WARNING NOTICES: (Please review notice that applies in your state) For applicants in Arkansas, Louisiana, New Mexico and Rhode Island: 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 fines and confinement in prison. For applicants in Colorado: 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. For applicants in District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the application. For applicants in Florida: 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. For applicants in Kentucky, New Mexico, Ohio, and Pennsylvania: 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. For applicants in Maine, Tennessee and Virginia: 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. For applicants in New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. For applicants in all other states: 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. UMERAPP (01/12) Attest: Jeffrey R. Smith, Clerk of Cir Court and Comptroller !/ Deputy Cleric s� n7- F 1, •�•r► <W�_7Fil►J�Ip Ede