Form Gn-65687-Hh - Humana Group Life Claim Form - Rogers Benefit Group Page 4
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4Group life claim fraud statements
Please refer to the statements that apply based upon the state where you live:
Alaska: A person who knowingly and with intent to injure,
Kentucky: Any person who knowingly and with intent to
defraud, or deceive an insurance company files a claim
defraud or deceive any insurance company or other person
containing false, incomplete, or misleading information may
files an application or claim for insurance containing any
be prosecuted under state law.
materially false information or conceals, for the purpose of
misleading, information concerning any fact material thereto
Arizona: For you protection Arizona law requires the
commits a fraudulent act, which is a crime.
following statement to appear on the form. Any person who
knowingly presents a false or fraudulent claim for payment of
Maine, Tennessee or Virginia: It is a crime to knowingly
a loss is subject to criminal and civil penalties.
provide false, incomplete or misleading information to an
insurance company for the purpose of defrauding the
Arkansas or Louisiana: Any person who knowingly presents
company. Penalties may include imprisonment, fines, or a
a false or fraudulent claim for payment of a loss or benefit or
denial of insurance benefits.
knowingly presents false information in an application for
insurance is guilty of a crime and may be subject to fines and
Minnesota: A person who files a claim with intent to
confinement in prison.
defraud or helps commit a fraud against an insurer is guilty of
a crime.
California: For your protection, California law requires the
following to appear on this form: any person who knowingly
New Hampshire: Any person who, with a purpose to injure,
presents a false or fraudulent claim for the payment of a loss
defraud or deceive any insurance company, files a statement
is guilty of a crime and may be subject to fines and
of claim containing any false, incomplete or misleading
confinement in state prison.
information is subject to prosecution and punishment for
insurance fraud, as provided in Section 638.20.
Colorado: It is unlawful to knowingly provide false,
incomplete, or misleading facts or information to an
New Jersey: Any person who knowingly files a statement of
insurance company for the purpose of defrauding or
claim containing any false or misleading information is subject
attempting to defraud the company. Penalties may include
to criminal and civil penalties.
imprisonment, fines, denial of insurance and civil damages.
New Mexico: Any person who knowingly presents a false
Any insurance company or agent of an insurance company
or fraudulent claim for payment of a loss or benefit or
who knowingly provides false, incomplete or misleading facts
knowingly presents false information in an application for
or information to a policyholder or claimant for the purpose
insurance is guilty of a crime and may be subject to civil fines
of defrauding or attempting to defraud a policyholder or
and criminal penalties.
claimant with regard to a settlement or award payable for
New York: Any person who knowingly and with intent to
insurance proceeds shall be reported to the Colorado
defraud insurance company or another person files an
Department of Insurance within the department of regulatory
application for insurance or statement of claim containing any
agencies.
materially false information or conceals for the purpose of
District of Columbia: Warning: It is a crime to provide false
misleading, information concerning any fact material thereto,
or misleading information to an insurer for the purpose of
commits a fraudulent act, which is a crime and shall also be
defrauding the insurer or any other person. Penalties include
subject to a civil penalty not to exceed $5,000 and the stated
imprisonment and/or fines. In addition, an insurer may deny
value of the claim for each violation.
insurance benefits if false information materially related to a
Ohio: Any person who, with intent to defraud, or knowing
claim was provided by the applicant.
that he is facilitating a fraud against an insurer, submits an
Florida: Any person who knowingly and with intent to injure,
application of false claim containing a false or deceptive
defraud, or deceive any insurer files a statement or claim or
statement is guilty of insurance fraud.
an application containing any false, incomplete, or misleading
Oklahoma: Any person who knowingly and with intent to
information is guilty of a felony.
injure, defraud, or deceive any insurer makes any claim for
Idaho: Any person who knowingly and with intent to
the proceeds of an insurance policy containing any false,
defraud or deceive any insurance company, files a statement
incomplete or misleading information is guilty of a felony.
or claim containing any false, incomplete, or misleading
Texas: Any person who knowingly presents a false or
information is guilty of a felony.
fraudulent claim for the payment of a loss is guilty of a crime
Indiana: Any person who knowingly and with intent to
and may be subject to fines and confinement in state prison.
defraud an insurer company, files a statement or claim
If you live in any state not listed above, the following
containing any false, incomplete, or misleading information,
applies to you: any person who knowingly files a statement
commits a felony.
of claim containing any false or misleading information may
be subject to criminal and civil penalties.
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GN-65687-HH 12/04
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