Please read the fraud warning statement applicable to applicable to your state. If your state is not shown, refer to the GENERAL FRAUD WARNING STATEMENT.
GENERAL FRAUD WARNING STATEMENT
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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 that person to criminal and/or civil penalties.
ALABAMA: Any person who knowingly presents a false or fraudulent claim for payment of 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 confinement in prison, or any combination thereof.
ARKANSAS, DISTRICT OF COLUMBIA, LOUISIANA, RHODE ISLAND and WEST VIRGINIA: Any person who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
CALIFORNIA: For your protection California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
KANSAS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that itwill be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic implulse, facsimile,magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of aninsurance policy for commercial or personal insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercialor personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, forthe purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.
KENTUCKY and PENNSYLVANIA: Any person who knowingly and with intent to defruad any insurance company or other person files anapplication 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 criminaland civil penalties.
MAINE: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defraudingthe company. Penalties may include imprisonment, fines or a denial of insurance benefits.
MARYLAND: Any person who knowingly or willingly presents a false or fraudulent claim for payment of a loss or benefit or 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.
COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for thepurpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civildamages. 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 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 ofRegulatory Agencies.
FLORIDA: Any Person who knowingly and with intent to inure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.
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 penalties.
OHIO: Any person who, with intent to defraud or knowing that he is facilitating a fraud againsta an insurer, submits an application of riles aclaim containing a false or deceptive statement is guilty of insurance fraud.
OKLAHOMA: WARNING: Any person who knowingly, and with 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.
VERMONT: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law
NEW YORK: 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 be subject to a civil penalty not to exceed five thousand dollars and the state value of the claim for each such violation.The undersigned declares that he/she/them has reviewed this application and any attachments and declares the information provided is true, correct and complete to the best of his/her/their knowledge.
OREGON: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an applicationcontaining a false statement as to any material fact may be violating state law.
TENNESSEE, VIRGINIA and 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.VERMONT: Any person who knowingly presents a false statement in an ap
