Group Benefit Services Application For Accidental Death Benefits - Mutual Of Omaha Insurance Company
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4Mutual of Omaha Insurance Company
Group Claim Fraud Statements
The following fraud language is attached to, and made part of this claim form. Please read and do not remove
these pages from this claim form.
** Alabama: 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 or confinement in prison, or any combination thereof.
** Alaska: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files
a claim containing false, incomplete, or misleading information may be prosecuted under state law.
** Arizona: Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to
criminal and civil penalties.
** Arkansas and Louisiana: 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.
** California: 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.
** Colorado: 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.
** Delaware: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a
statement of claim containing any false, incomplete or misleading information is guilty of a felony.
** District of Columbia: WARNING: It is a crime to provide false or misleading information to an 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: 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.
** Idaho: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a
statement containing any false, incomplete, or misleading information is guilty of a felony.
** Indiana: A person who knowingly and with intent to defraud an insurer files a statement of claim
containing any false, incomplete, or misleading information commits a felony.
** Kentucky: 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.
** Maine: 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.
MUG6774_0812
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