We must advise you that any person who knowingly and with intent to defraud any insurance company files a statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact thereto, commits a fraudulent insurance act, which is a crime and may be prosecuted to the full extent of the law. By signing, I agree that the statements above are true and correct to the best of my knowledge and cannot be changed once submitted to the company.