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NOTICE TO ALASKA RESIDENT APPLICANTS: A
person who knowingly and with the intent to
injure, defraud, or deceive an insurance company
files a claim containing false, incomplete, or
misleading information is guilty of a felony.
NOTICE TO ARKANSAS RESIDENT APPLICANTS: Any
person who knowingly presents a false or
fraudulent claim for payment of a loss or
benefit or knowingly presents false information
in an application for insurance may be guilty of
a crime and subject to fines and confinement in
prison.
NOTICE TO CALIFORNIA RESIDENT APPLICANTS: For
your protection California law requires the
following to appear on this form. Any person who
knowingly presents false or fraudulent claim for
the payment of a loss is guilty of a crime and
may be subject to fines and confinement in
prison. Any person who knowingly files a
statement of claim containing any false or
misleading information is subject to criminal
and civil penalties.
NOTICE TO COLORADO RESIDENT APPLICANTS: It
is unlawful to knowingly provide false,
incomplete or misleading facts or information to
an insurance company for the purpose of
defrauding or attempting to defraud the company.
Penalties may include imprisonment, fines,
denial of insurance and civil damages. Any
insurance company or agent of an insurance
company who knowingly provides false, incomplete
or misleading facts or information to a
policyholder or claimant for the purpose of
defrauding or attempting to defraud the policy
holder or claimant with regard to a settlement
or award payable from insurance proceeds shall
be reported to the Colorado Division of
Insurance within the Department of Regulatory
Agencies.
NOTICE TO DELAWARE RESIDENT APPLICANTS:
Any person who knowingly, and with the intent to
injure, defraud or deceive an insurer, files a
statement of claim containing any false,
incomplete or misleading information is guilty
of a felony.
NOTICE TO DISTRICT OF COLUMBIA RESIDENT
APPLICANTS: WARNING: It
is a crime to provide false or misleading
information to an insurer for the purpose of
defrauding the insurer or any other person.
Penalties include imprisonment and/or fines. In
addition, any insurer may deny insurance
benefits if false information materially related
to a claim was provided by the applicant.
NOTICE TO FLORIDA RESIDENT APPLICANTS: Any
person who knowingly and with intent to injure,
defraud or deceive any insurer files a false
statement of claim or an application) containing
any false, incomplete or misleading information
is guilty of a felony of the third degree.
NOTICE TO HAWAII RESIDENT APPLICANTS: For
your protection, Hawaii law requires you to be
informed that presenting a fraudulent claim for
payment of a loss or benefit is a crime punish
able by fines, imprisonment or both.
NOTICE TO IDAHO RESIDENT APPLICANTS: Any
person who knowingly, and with the intent to
defraud or deceive any false, incomplete or
misleading information is guilty of a felony.
NOTICE TO INDIANA RESIDENT APPLICANTS: A
person who knowingly and with the intent to
defraud an insurer files a statement of claims
containing any false, incomplete or misleading
information commits a felony.
NOTICE TO KENTUCKY RESIDENT APPLICANTS: Any
person who knowingly and with the intent to
defraud an 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.
NOTICE TO LOUISIANA, MAINE AND TENNESSEE
RESIDENT APPLICANTS: Any
person who knowingly and with the intent to
defraud any insurance company or another person,
files a statement of claim contain 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,
subject to criminal prosecution and civil
penalties. Insurance benefits may also be
denied.
NOTICE TO MINNESOTA RESIDENT APPLICANTS: A
person who submits an application or files a
claim with intent to defraud or helps commit a
fraud against an insurer is guilty of a crime.
NOTICE TO NEBRASKA RESIDENT APPLICANTS:
Any person who knowingly presents false
information in an application for insurance or
viatical settlement contract is guilty of a
crime and may be subject to fines and
confinement in prison.
NOTICE TO NEVADA RESIDENT APPLICANTS: Pursuant
to NRS 686A.291, any person who knowingly and
willfully files a statement that contains any
false, incomplete or misleading information
concerning a material fact is guilty of a
felony.
NOTICE TO NEW HAMPSHIRE RESIDENT APPLICANTS: Any
person who, with the purpose to injure, defraud
or deceive any insurance company, files a
statement of claim containing any false,
incomplete or misleading information is subject
to prosecution and punishment for insurance
fraud, as provided in RSA 638:20.
NOTICE TO NEW JERSEY RESIDENT APPLICANTS: Any
person who includes any false or misleading
information on an application for an insurance
policy is subject to criminal and civil
penalties.
NOTICE TO NEW MEXICO RESIDENT APPLICANTS: Any
person who knowingly presents false information
in an application for insurance is guilty of a
crime and may be subject to civil fines and
criminal penalties.
NOTICE TO NEW YORK RESIDENT APPLICANTS: Any
persons who knowingly and with the 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 five thousand
dollars and the stated value of the claim for
each such violation.
NOTICE TO OHIO RESIDENT APPLICANTS: Any
person who, with the intent to defraud or
knowing that he is facilitating a fraud against
an insurer, submits an application or files a
claim containing a false or deceptive statement
is guilty of insurance fraud.
NOTICE TO OKLAHOMA RESIDENT APPLICANTS: WARNING:
Any person who knowingly and with the intent to
injure, defraud or deceive any insurer, makes
any claim for the proceeds of an insurance
policy containing any false, incomplete or
misleading information is guilty of a felony.
NOTICE TO OREGON RESIDENT APPLICANTS: Any
person who knowingly presents a false or
fraudulent claim for payment of a loss or
benefit or knowingly presents materially false
information in an application for insurance may
be guilty of a crime and may be subject to fines
and confinement in prison.
NOTICE TO PENNSYLVANIA RESIDENT APPLICANTS: Any
person who knowingly and with the 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
thereto commits a fraudulent insurance act,
which is a crime and subjects such a person to
criminal and civil penalties.
NOTICE TO UTAH RESIDENT APPLICANTS: For
your protection, Utah law requires the following
to be included in this application: Any person
who knowingly presents false or fraudulent
underwriting information, files or causes to be
filed a false or fraudulent claim for disability
compensation or medical benefits, or submits a
false or fraudulent report or billing for health
care fees or other professional services is
guilty of a crime and may be subject to fines
and confinement in state prison.
NOTICE TO VIRGINIA RESIDENT APPLICANTS: It
is a crime to knowingly provide false,
incomplete or misleading information to an
insurance company for the purpose of defrauding
the company. Penalties include imprisonment,
fines and denial of insurance benefits.
NOTICE TO WASHINGTON RESIDENT APPLICANTS: It
is a crime to knowingly provide false,
incomplete, or misleading information to an
insurance company for the purposes of defrauding
the company. Penalties include imprisonment,
fines and denial of insurance benefits.
NOTICE TO WEST VIRGINIA RESIDENT APPLICANTS: Any
person who knowingly presents a false or
fraudulent claim for payment of a loss or
benefit or knowingly presents false information
in an application for insurance is guilty of a
crime and may be subject to fines and
confinement in prison |
