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 civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation *State of NY only. "Fair Credit Reporting Act Notice" This notice is given to comply with the Federal fair Credit Reporting Act (Public law 91-508) and any similar state law which is applicable. As part of our underwriting procedure, a routine credit report may be pulled on any applicant or indemnitor which will provide information concerning credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics and mode of living. Upon request, additional information as to the nature and scope of the report, if one is made, will be provided. The above is only a conditional offer and is subject to change or rescission based upon a multitude of considerations. The above quoted may include a broker fee. Therefore, the undersigned hereby agrees that if a fee is charged, to pay the fee in the amount of as shown above. First Years premium, renewals, minimum premiums and commission are fully earned, upon issuance of the bond(s), unless prohibited by law, "or is contrary to Surety's filed rates”. If the Bond is canceled midterm, the commission shall also be considered a fee, and fully earned. In addition, fees and premiums may earn interest. This undeclared income is non-refundable and fully earned as well as any fees charged. In addition, Worldwide Insurance Specialists, Inc. may also be acting on behalf of the insurer issuing the subject Bond(s) or insurance and will be receiving a commission. If a rider is issued due to incorrect information provided to Worldwide Insurance Specialists, Inc. and the bond has left our office the principal will incur a rider fee. If the bond is lost / destroyed and a duplicate bond is issued the principal will incur a rider fee. If any portion of this Agreement is unenforceable that portion shall be considered deleted with the remainder to continuing in full force and effect. The Principal and its employees or Agent/Broker shall be responsible for any and all liability resulting from its own acts and omissions as well as the acts and omissions of its sub-agents, sub-brokers, and its and their employees, and shall indemnify Worldwide Insurance Specialists, Inc. and hold harmless for any claims or damages arising therefrom, including any award, judgment, penalties, fees, costs of court, and or reasonable attorneys’ fees incurred in defending same. This agreement shall serve as the writing required pursuant to the rules set forth by your Department of Insurance (Broker/Agents shall comply with their applicable state regulations regarding fees). **Fees include processing, state tax, surplus tax, brokers and commission fee where applicable.