Fillable Proof Of Claim Form (Page 4 of 5) in pdf

New Hampshire: Any person who, with a purpose to injure, defraud or deceive any

insurance company, files a statement of claim containing any false, incomplete or

misleading information is subject to prosecution and punishment for insurance fraud, as

provided in section 638:20.

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

misleading information is subject to criminal and civil penalties.

New Mexico: 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 civil fines and criminal penalties.

New York: 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 five thousand dollars and the

stated value of the claim for each such violation.

Ohio: Any person who, with 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 is guilty of insurance fraud.

Oklahoma: 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.

Oregon: Any person who knowingly and with intent to defraud or solicit another to defraud

an insurer: (1) by submitting an application, or (2) by filing a claim containing a false

statement as to any material fact, may be violating state law.

Pennsylvania: 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: 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: 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: 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.

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 include

imprisonment, fines and denial of insurance benefits.

West Virginia: 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.

Proof Of Claim Form Page 4