General Instruction For Court Forms (Page 5 of 8) in pdf

Anti-Fraud Notice

The following disclaimer applies only to applicants in the states of Washington and

Florida.

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

statement of claim or an application containing any false, incomplete, or misleading information

is guilty of a felony of third degree.”

Anti-Fraud Warning

Applicable to Maine, Tennessee and Virginia Applicants only

“It is a crime to knowingly provide false, incomplete or misleading information to an insurance

company for the purpose of defrauding the company. Penalties include imprisonment, fines and

denial of insurance benefits”.

Anti-Fraud Warning

Applicable to New York Applicants only

“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 such

violation.”

Anti-Fraud Notice

Applicable to Kentucky Applicants Only

“Any person who knowingly and with intent to defraud any insurance company or other person

files an application for insurance 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.”

Anti-Fraud Notice

Applicable to Ohio Applicants Only

"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."

Anti-Fraud Notice

Applicable to New Mexico, West Virginia and Louisiana Applicants Only

"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.”

Anti-Fraud Notice

Applicable to DC Applicants Only

“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.”

FA004 – Application for Court Bonds Other than Probate – 4/2012

General Instruction For Court Forms Page 5