The following language must be included on any form that the insured signs that collects information from the
insured (for example, application or acreage report).
I certify that to the best of my knowledge and belief all of the information on this form is correct. I also
understand that failure to report completely and accurately may result in sanctions under my policy, including
but not limited to voidance of the policy, and in criminal or civil penalties
(18 U.S.C. §1006 and §1014; 7 U.S.C. §1506; 31 U.S.C. §3729, §3730 and any other applicable federal statutes).
For more information, contact Pam Bollinger.