Common use of Signature Authorization Clause in Contracts

Signature Authorization. Employer represents that the information on this application is true and accurate to the best of its knowledge. 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 a civil penalty not to exceed $5,000 and the stated value for the claim for each such violation. By signing below, Employer and Capital District Physicians’ Healthcare Network, Inc. hereby agree to the Terms and Conditions attached hereto and incorporated herein. Capital District Physicians’ Healthcare Network, Inc., by: Signature: Date Print name: Employer, by: Signature: Date Print name: Print title: Broker’s signature: Date Print name: Account Rep’s signature: Date Print name: TERMS AND CONDITIONS

Signature Authorization. Employer represents that the information on this application is true and accurate to the best of its knowledge. 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 a civil penalty not to exceed $5,000 and the stated value for the claim for each such violation. By signing below, Employer and Capital District Physicians’ Healthcare Network, Inc. hereby agree to the Terms and Conditions attached hereto and incorporated herein. Capital District Physicians’ Healthcare Network, Inc., by: Signature: Date Print name: Xxxxxx Xxxxxxx, CHIE, PMP, Senior Vice President, Consumer Experience Solutions Employer, by: Signature: Date Print name: Print title: Broker’s signature: Date Print name: Account Rep’s signature: Date Print name: TERMS AND CONDITIONS

Signature Authorization. Employer represents that the information on this application is true and accurate to the best of its knowledge. 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 a civil penalty not to exceed $5,000 and the stated value for the claim for each such violation. By signing below, Employer and Capital District Physicians’ Healthcare Network, Inc. hereby agree to the Terms and Conditions attached hereto and incorporated herein. Capital District Physicians’ Healthcare Network, Inc., by: Signature: Date Print name: Employer, by: Signature: Date Print name: Print title: Broker’s signature: Date Print name: Account Rep’s signature: Date Print name: TERMS AND CONDITIONS

Signature Authorization. Employer represents that the information on this application is true and accurate to the best of its knowledge. 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 a civil penalty not to exceed $5,000 and the stated value for the claim for each such violation. By signing below, Employer and Capital District Physicians’ Healthcare Network, Inc. hereby agree to the Terms and Conditions attached hereto and incorporated herein. Capital District Physicians’ Healthcare Network, Inc., by: Signature: Date Print name: Xxxx Xxxxx, Chief Sales and Marketing Officer Employer, by: Signature: Date Date Print name: Print title: Broker’s signature: Date Print name: Account Rep’s signature: Date Print name: TERMS AND CONDITIONS