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5600-FM-BMP0144 10/2013

COMMONWEALTH OF PENNSYLVANIA

DEPARTMENT OF ENVIRONMENTAL PROTECTION

BUREAU OF MINING PROGRAMS

MINE SUBSIDENCE INSURANCE FUND

MINE SUBSIDENCE INSURANCE POLICY ENDORSEMENT

DAMAGE EXCLUSION STATEMENT

This policy only covers damages that occur while a structure is insured and that are the result of mine subsidence.

Any damage that has occurred prior to the policy period is specifically excluded from coverage.

Applicant's Name      

Insured Structure Address      

     

Applicant's Signature Date       /      /     

Title 18 (Crimes and Offenses) of the Pennsylvania Consolidated Statutes, Section 4117 (providing for Insurance Fraud) (1990) establishes that insurance fraud is a crime punishable by both fines and imprisonment.

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.



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