Fillable Colonial Life Health/wellness Screening Claim Form

Colonial Life | HEALTH/WELLNESS SCREENING | Fax: 1-800-880-9325 | Telephone: 1-800-325-4368

Claim Fraud Statements

For your protection, the laws of several states, including Alaska, Arkansas, Delaware, Idaho, Indiana, Louisiana, Minnesota,

New Hampshire, Ohio, Oklahoma, and others, require the following statement to appear on this claim form. Fraud Warning: Any

person who knowingly, and with intent to injure, defraud, or deceive an insurance company, files a statement of claim containing

any false, incomplete, or misleading information is guilty of insurance fraud, which is a felony.

Alabama: Any person who knowingly presents a false or fraudulent claim

Maryland: Any person who knowingly or willfully presents

for payment of a loss or benefit or who knowingly present false information

a false or fraudulent claim for payment of a loss or benefit

in an application for insurance is guilty of a crime and may be subject to

or who knowingly or willfully presents false information in

an application for insurance is guilty of a crime and may be

restitution fines or confinement in prison, or any combination thereof.

subject to fines and confinement in prison.

Arizona: For your protection Arizona law requires the following

statement to appear on this form: Any person who knowingly

New Jersey and New Mexico: Any person who knowingly

files a statement of claim containing any false or misleading

presents a false or fraudulent claim for payment of a loss is

information is subject to criminal and civil penalties.

subject to criminal and civil penalties.

New York: Any person who knowingly and with intent to

California, Rhode Island, Texas and West Virginia: For your protection,

defraud any insurance company or other person files an

California, Rhode Island, Texas and West Virginia law requires the following

application for insurance or statement of claim containing

to appear on this form: Any person who knowingly presents false or

any materially false information, or conceals for the purpose

fraudulent claim for the payment of a loss is guilty of a crime and may

of misleading, information concerning any fact material

be subject to fines and confinement in state prison.

thereto, commits a fraudulent insurance act, which is a crime,

Colorado: It is unlawful to knowingly provide false, incomplete, or misleading

and shall also be subject to a civil penalty not to exceed five

facts or information to an insurance company for the purpose of defrauding

thousand dollars and the stated value of the claim for each

or attempting to defraud the company. Penalties may include imprisonment,

such violation.

fines, denial of insurance and civil damages. Any insurance company or

Pennsylvania: Any person who knowingly and with intent

agent of an insurance company who knowingly provides false, incomplete,

to defraud any insurance company or other person files an

or misleading facts or information to a policyholder or claimant for the

application for insurance or statement of claim containing

purpose of defrauding or attempting to defraud the policyholder or claimant

any materially false information or conceals for the purpose

with regard to a settlement or award payable from insurance proceeds shall

of misleading, information concerning any fact material

be reported to the Colorado Division of Insurance within the Department of

thereto commits a fraudulent insurance act, which is a crime

Regulatory Agencies.

and subjects such person to criminal and civil penalties

District of Columbia: It is a crime to provide false or misleading information

Puerto Rico: Any person who knowingly and with the

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

intention of defrauding presents false information in an

deny insurance benefits if false information materially related to a claim

insurance application, or presents, helps, or causes the

was provided by the applicant.

presentation of a fraudulent claim for the payment of a loss

or any other benefit, or presents more than one claim for

Florida: Any person who knowingly and with intent to injure, defraud, or

the same damage or loss, shall incur a felony and, upon

deceive any insurer files a statement of claim or an application containing

conviction, shall be sanctioned for each violation with the

any false, incomplete, or misleading information is guilty of a felony of the

penalty of a fine of not less than five thousand (5,000)

third degree.

dollars and not more than ten thousand (10,000) dollars,

Kentucky: For your protection, Kentucky law requires the following to

or a fixed term of imprisonment for three (3) years, or both

appear on this form: Any person who knowingly and with intent to defraud

penalties. If aggravating circumstances are present, the

any insurance company or other person files a statement of claim

penalty thus established may be increased to a maximum

containing any materially false information or conceals, for the purpose

of five (5) years; if extenuating circumstances are present;

of misleading, information concerning any fact material thereto commits

it may be reduced to a minimum of two (2) years.

a fraudulent insurance act, which is a crime.

Maine, Tennessee, Virginia and Washington: It is a crime to knowingly

provide false, incomplete or misleading information to an insurance

company for the purpose of defrauding the company. Penalties may

include imprisonment, fines or a denial of insurance benefits.

Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. |

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Colonial Life Health/wellness Screening Claim Form - 2015 Page 2

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