Member Claim Form - Cigna Healthcare (Page 3 of 3) in pdf

Caution: Any person who, knowingly and with intent to defraud any insurance company or other person: (1) files an application

for insurance or statement of claim containing any materially false information; or (2) conceals for the purpose of misleading,

information concerning any material fact thereto, commits a fraudulent insurance act.

IMPORTANT CLAIM NOTICE

Alaska Residents: A person who knowingly and with intent to injure, defraud or deceive an insurance company or files a claim

containing false, incomplete or misleading information may be prosecuted under state law.

Arizona Residents: For your protection, Arizona law requires the following statement to appear on/with this form. Any person

who knowingly presents a false or fraudulent claim for payment of loss is subject to criminal and civil penalties.

California Residents: For your protection, California law requires the following to appear on/with 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.

District of Columbia Residents: 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.

Florida Residents: 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 the third degree.

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.

Maryland Residents: Any person 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.

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

crime.

New Jersey Residents: Any person who knowingly files a statement of claim containing any false or misleading information is

subject to criminal and civil penalties.

New York 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 shall also

be subject to a civil penalty not to exceed $5000 and the stated value of the claim for each such violation.

Oregon Residents: Any person who knowingly and with intent to defraud any insurance company or other person: (1) files an

application for insurance or statement of claim containing any materially false information; or, (2) conceals for the purpose of

misleading, information concerning any material fact, may have committed a fraudulent insurance act.

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.

Tennessee Residents: 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.

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.

Virginia Residents: Any person who, with the 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 may have violated state law.

591692a Rev. 10/2008

Member Claim Form - Cigna Healthcare Page 3

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