Physician Statement Stroke Claim Form (Page 3 of 3) in pdf

FRAUD WARNING NOTICE

The laws of some states require us to furnish you with the following notice:

Alabama – Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly

presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confine-

ment in prison, or any combination thereof.

Arkansas, Louisiana, Massachusetts, Rhode Island – Any person who knowingly presents a false or fraudulent claim for pay-

ment 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.

Colorado – It is unlawful to knowingly provide false, incomplete, or misleading material 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 material facts or information to a policyholder or claimant for the purpose of defrauding or attempt-

ing to defraud the policyholder 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.

District of Columbia – WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of de-

frauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance

benefits if false information materially related to a claim was provided by the applicant.

Florida – Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an ap-

plication containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

Hawaii – 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 punishable by fines or imprisonment, or both.

Kentucky – Any person who knowingly and with intent to defraud any insurance company or other person files an application for

insurance or a statement of claim containing any materially false information or conceals, for the purpose of misleading, informa-

tion concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

Maine, Tennessee, Virginia, Washington – 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.

Maryland – Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who

knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines

and confinement in prison.

Minnesota – 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.

New Jersey – Any person who includes any false or misleading information on an application for an insurance policy is subject

to criminal and civil penalties.

New Mexico – 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 civil fines and criminal penal-

ties.

Ohio – Any person who, with 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.

Oklahoma – Any person who knowingly, with intent to injure, defraud or deceive any insurer, makes a claim for the proceeds of

an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Pennsylvania – Any person who knowingly and with intent to defraud any insurance company or other person files an applica-

tion 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.

Puerto Rico – Any person who knowingly and with the intention of defrauding presents false information in an insurance ap-

plication, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or

presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for

each violation with the penalty of a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars

($10,000) or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present,

the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may

be reduced to a minimum of two (2) years.

All Other States – Any person who knowingly presents a false statement in an application for insurance may be guilty of a crimi-

nal offense and subject to penalties under state law.

Products and services are underwritten and/or provided by Colorado Bankers Life Insurance Company

Fraud Notice 11-14 REV 08-15 Page 3 of 3

Physician Statement Stroke Claim Form Page 3

Related Articles

Related forms

Related Categories