Draw boxes showing City Auto (C), Your Auto (1) and Other Autos (2,3).
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
Person(s) who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self-insured program, dies a statement of claim containing any false or misleading information, commits insurance fraud, punishable as provided in FS. 817.234.
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