Applicable in Arizona
For your protection, Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
Applicable in Arkansas, District Of Columbia, Kentucky, Louisiana, Maine, Michigan, New Jersey, New Mexico, Pennsylvania, Tennessee, Virginia and West Virginia
Any person who knowingly and with intent to defraud any insurance company or another person, iles a 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, subject to criminal prosecution and civil penalties. In DC, LA, ME, TN and VA insurance beneits may also be denied.
Applicable in 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 ines and coninement in state prison.
Applicable in Colorado
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, ines, 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 policy holder 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 Regulator y Agencies.
Applicable in Delaware, Florida and Idaho
Any person who knowingly and with the intent to injure, Defraud, or Deceive any Insurance Company Files a Statement of Claim Containing any False, Incomplete or Misleading is Guilty of a Felony. *
*In Florida – Third Degree Felony
Applicable in Hawaii
For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or beneit is a crime punishable by ines or imprisonment, or both.
Applicable in Indiana
A person who knowingly and with intent to defraud an insurer iles a statement of claim containing any false, incomplete, or misleading information commits a felony.
Applicable in Minnesota
A person who iles a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
Applicable in Nevada
Pursuant to NRS 686A.291, any person who knowingly and willfully iles a statement of claim that contains any false, incomplete or misleading information concerning a material fact is guilty of a felony.
Applicable in New Hampshire
Any person who, with the purpose to injure, defraud or deceive any insurance company, iles 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.
Applicable in New York
Any person who knowingly and with intent to defraud any insurance company or other person iles an application for commercial insurance or a statement of claim for any commercial or personal insurance beneits containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person who in connection with such application or claim knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false repor t of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the Department of Motor Vehicles or an insurance company, commits fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed ive thousand dollars and the value of the subject motor vehicle or stated claim for each violation.
Applicable in Ohio
Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or iles a claim containing a false or deceptive statement is guilty of insurance fraud.
Applicable in 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.