General Instruction For Court Forms (Page 6 of 8) in pdf

Anti-Fraud Notice

Applicable to Indiana Applicants Only

"Any person who knowingly, and with intent to defraud an insurer, files a statement of claim

containing false presents, incomplete or misleading information commits a felony.”

Anti-Fraud Notice

Applicable to Hawaii Applicants Only

“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.”

Anti-Fraud Notice

Applicable to New Jersey Applicants Only

“Any person who includes any false or misleading information on an application for an insurance

policy is subject to criminal and civil penalties.”

Anti-Fraud Notice

Applicable to Pennsylvania 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 subjects such person to criminal and

civil penalties.”

Anti-Fraud Notice

Applicable to Oklahoma Applicants Only

“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.”

Anti-Fraud Notice

Applicable to Colorado Applicants Only

“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.”

Anti-Fraud Notice

Applicable to Maryland Applicants Only

"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.”

Anti-Fraud Notice

Applicable to Alabama Applicants Only

"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 and confinement in prison, or any combination thereof.”

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

General Instruction For Court Forms Page 6

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