Jrotc Insurance Form - Elkin City Schools Page 4
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4Fraud Warning: Any person who, with the intent to defraud or knowingly facilitates a fraud against an
insurer, submits an application or files a claim containing a false or deceptive statement, or conceals
information for the purpose of misleading may be guilty of insurance fraud and subject to criminal and/or
civil penalties.
Please see the following for a list of any specific warning as required:
Arizona Residents: 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 Residents: For your protection California law requires the following to appear on this form.
Any person who knowingly presents a 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 Residents: 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 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.
Hawaii Residents: 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.
Idaho Residents: Any person who knowingly and with intent to defraud or deceive any insurance
company, files a statement or claim containing a false, incomplete, or misleading information is guilty of
a felony.
Kentucky Residents: Any person who knowingly and with intent to defraud any insurance company or
other person files 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.
Oklahoma Residents: 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.
Pennsylvania Residents: 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.
Texas Residents: Any person who knowingly presents a 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.
Form Number USFIC FLD 2011
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