Fillable College Medical Withdrawal Certificate Form (Page 2 of 2) in pdf

IMPORTANT NOTICE

To Arizona Claimants

To Minnesota Claimants

For your protection Arizona law requires the

A person who files a claim with intent to defraud or helps

commit a fraud against an insurer is guilty of a crime.

following statement to appear on this form.

Any person who knowingly presents a false

To New Hampshire Claimants

or fraudulent claim for payment of a loss is

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

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

subject to criminal and civil penalties.

incomplete or misleading information is subject to prosecution and

punishment for insurance fraud, as provided in RSA 638:20.

CLAIMANTS

ARKANSAS,

LOUISIANA,

To New Jersey Claimants

MARYLAND AND TEXAS,

Any person who knowingly files a statement of claim containing any

ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR

false or misleading information is subject to criminal and civil

FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT

penalties.

OR (in AR, LA or MD) KNOWINGLY PRESENTS FALSE

INFORMATION IN AN APPLICATION FOR INSURANCE IS

TO NEW MEXICO CLAIMANTS

GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND

ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR

CONFINEMENT IN PRISON.

FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT

OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN

To California Claimants

APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND

For your protection California law requires the

MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES.

following to appear on this form: Any person who

To New York Claimants

knowingly presents false or fraudulent claim for the

Any person who knowingly and with intent to defraud any insurance

payment of a loss is guilty of a crime and may be

company or other person files an application for insurance or

subject to fines and confinement in state prison.

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

To Colorado Claimants

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

It is unlawful to knowingly provide false, incomplete, or

thousand dollars and the stated value of the claim for each such

misleading facts or information to an insurance

violation.

company for the purpose of defrauding or attempting

To Ohio Claimants

to defraud the company. Penalties may include

Any person who, with intent to defraud or knowing that he is

imprisonment, fines, denial of insurance, and civil

facilitating a fraud against an insurer, submits an application or files

damages. Any insurance company or agent of an

a claim containing a false or deceptive statement is guilty of

insurance company who knowingly provides false,

insurance fraud.

incomplete, or misleading facts or information to a

To Oklahoma Claimants

policyholder or claimant for the purpose of defrauding

WARNING: Any person who knowingly, and with intent to injure,

or attempting to defraud the policyholder or claimant

defraud or deceive any insurer, makes any claim for the proceeds of

with regard to a settlement or award payable from

an insurance policy containing any false, incomplete or misleading

insurance proceeds shall be reported to the Colorado

information is guilty of a felony.

division of insurance within the department of

To Oregon Claimants

regulatory agencies.

Any person who knowingly and with the intent to defraud any

insurer provides false or misleading information concerning any fact

To Claimants in Delaware, Idaho and Indiana

material to a risk to be insured or to a claim for loss or benefits may

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

be guilty of a crime.

deceive any insurer, files a statement of claim containing any false,

incomplete or misleading information is guilty of a felony.

To Pennsylvania Claimants

Any person who knowingly and with intent to defraud any insurance

To Florida Claimants

company or other person files an application for insurance or

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

statement of claim containing any materially false information or

deceive any insurer, files a statement of claim containing any false,

conceals for the purpose of misleading, information concerning any

incomplete, or misleading information is guilty of a felony of the third

fact material thereto commits a fraudulent insurance act, which is a

degree.

crime and subjects such person to criminal and civil penalties.

To Kentucky Claimants

To Claimants in Virginia, Washington and any

Any person who knowingly and with intent to defraud any insurance

State not listed above

company or other person files a statement of claim containing any

It is a crime to knowingly provide false, incomplete, or misleading

materially false information or conceals, for the purpose of

information to an insurance company for the purpose of defrauding

misleading, information concerning any fact material thereto

the company. Penalties include imprisonment, fines or a denial of

commits a fraudulent insurance act, which is a crime.

insurance benefits.

College Medical Withdrawal Certificate Form Page 2

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