Active Beneficiary Verification Form - New Jersey Department Of The Treasury (Page 2 of 2) in pdf

CALIFORNIA RESIDENTS – 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.

DISTRICT OF COLUMBIA RESIDENTS – 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.

FLORIDA RESIDENTS – Any person knowingly and with intent to injure, defraud, or deceive any insurer files

a statement of claim or an application containing 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.

NEW JERSEY RESIDENTS – Any person who knowingly files a statement of claim containing any false or mis-

leading 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 fraudu-

lent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dol-

lars and the stated value of the claim for each such violation.

PENNSYLVANIA AND UTAH RESIDENTS – Any person who knowingly and with intent to defraud any insur-

ance company or other person files an application for insurance or statement of claim containing any material-

ly false information or conceals for the purpose of misleading, information concerning any material fact thereto

commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

VERMONT RESIDENTS – Any person who knowingly presents a false or fraudulent claim for payment of a loss

or knowingly makes a false statement in an application for insurance may be guilty of a criminal offense under

state law.

VIRGINIA RESIDENTS – Any person who knowingly and with intent to injure, defraud, or deceive any insur-

ance company or other person, or knowing that he is facilitating commission of a fraud, submits incomplete,

false, fraudulent, deceptive or misleading facts or information when filing a statement of claim for payment of a

loss or benefit may have violated state law, is guilty of a crime and may be prosecuted and punished under state

law. Penalties may include fines, civil damages and criminal penalties, including confinement in prison. In addi-

tion, an insurer may deny insurance benefits if false information materially related to a claim was provided by

the applicant or if the applicant conceals, for the purpose of misleading, information concerning any fact mate-

rial thereto.

WASHINGTON RESIDENTS – Any person who knowingly provides false, incomplete, or misleading information

to an insurance company for the purpose of defrauding the company commits a crime. Penalties include impris-

onment, fines, and denial of insurance benefits.

For residents of all states except California, the District of Columbia, Florida, Kentucky, New Jersey, New

York, Pennsylvania, Utah, Vermont, Virginia and Washington;

WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or

other person, or knowing that he is facilitating commission of a fraud, submits incomplete, false, fraudulent,

deceptive or misleading facts or information when filing an insurance application or a statement of claim for pay-

ment of a loss or benefit commits a fraudulent insurance act, is/may be guilty of a crime and may be prosecut-

ed and punished under state law. Penalties may include fines, civil damages and criminal penalties, including

confinement in prison. In addition, an insurer may deny insurance benefits if false information materially related

to a claim was provided by the applicant or if the applicant conceals, for the purpose of misleading, information

concerning any fact material thereto.

Active Beneficiary Verification Form - New Jersey Department Of The Treasury Page 2

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