Form Glc10115 - Wellness Benefit Claim Form (Page 2 of 3) in pdf

FRAUD NOTICES. For your protection, certain states require that the following notices appear on this form.

Alaska. 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.

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.

Arkansas, Louisiana, Rhode Island and 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 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 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 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.

Delaware. Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement

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

District of Columbia. 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.

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

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

Idaho. Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement

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

Indiana. A person who knowingly and with intent to defraud an insurer files a statement of claim containing any

false, incomplete, or misleading information commits a felony.

Kentucky. 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.

Maine. It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for

the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

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

benefit or 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.

Minnesota. A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty

of a crime.

New Hampshire. Any person who, with a purpose to injure, defraud or deceive any insurance company, files

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.

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GLC10115

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Form Glc10115 - Wellness Benefit Claim Form Page 2

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