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FRAUD WARNING NOTICES

Any person who knowingly and with intent to defraud, injure or deceive an insurance company or other person files a statement of

claim or application containing any materially false or misleading information or conceals for the purpose of misleading, information

concerning any fact material thereto, may be guilty of a crime and may be subject to civil penalties, fines, and/or imprisonment.

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 confinement in prison, or

any combination thereof.

Alaska, Minnesota, New Hampshire: A person who knowingly and with intent to injure, defraud, or deceive an insurance company

files a claim containing false, incomplete, or misleading information may be prosecuted under state law.

Arkansas, Louisiana, New Mexico, Texas, West Virginia: 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.

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.

California: 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 state prison.

Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to any 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 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.

Maine, Virginia, Tennessee, Washington: It is a crime to knowingly provide false, incomplete or misleading information to an

insurance company for the purpose of defrauding the company 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.

Delaware, Idaho, Indiana: Any person who knowingly, and with intent to injure, defraud or deceive any insurer files a statement of

claim containing any false or misleading information is guilty of a felony.

Florida: Any person who knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or

self insured program files a statement of claim or an application containing any false or misleading information commits insurance

fraud, punishable as provided in section 817.234.

District of Columbia: 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, an insurer may deny insurance benefits, if

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

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.

Kentucky, Pennsylvania: 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 subjects such person to

criminal and civil penalties.

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

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

confinement in prison.

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 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 also be subject to a civil penalty

not to exceed five thousand dollars and the stated value of the claim for each violation.

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.

Oregon: Any person who knowingly and with intent to defraud, files a claim for benefits may be guilty of insurance fraud and may be

subject to prosecution.

LC-7363-1 (MLIC)

Page 2 of 2

9/2012

Form Lc-7363-1 (Mlic) - Statement Of Claim And Instructions On How To Submit A Tricare/champva Supplement Claim Page 2

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