Important notice regarding the fair credit reporting act: in making this application for insurance it is understood that as part of our underwriting procedure, an investigative consumer report may be prepared whereby information is obtained through personal interviews with you neighbors, friends, or others with whom you are acquainted. This inquiry includes information as to your character, general reputation, personal characteristics, and mode of living. If an investigation is made, you can be assured that it will be handled in the strictest confidence. If you wish information on the nature and scope of the customer report which may be requested, ask your agent for the address of the company handling your account.

Any person who knowingly and with intent to defraud any insurance company or other person files and 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.

Applicant's statement: I have read the above application and I declare that to the best or my knowledge and belief all of the foregoing statements are true. In addition, if the Kentucky automobile assigned risk plan or company designated in this application is non standard. I certify that I understand that the rates for this coverage are higher than normal, and that they are acceptable to me as I have been unable to obtain coverage desired through the normal insurance market.