Hospital Indemnity Claim Form - Gtl (Page 4 of 5) in pdf

Dear Insured:

Below is a listing of the fraud language that your State Department of Insurance requires us to give to you.

Please first locate your state of residence and then read the fraud language that pertains to your state. Thank you.

Connecticut

Massachusetts

Nebraska

South Dakota

Georgia

Michigan

North Carolina

Utah

Hawaii

Missouri

North Dakota

Vermont

Iowa

Mississippi

Nevada

Wisconsin

Illinois

Montana

South Carolina

Wyoming

Kansas

Generic Fraud Warning (to be used for above

imprisonment, fines, denial of insurance and

states only)

Any person who knowingly presents a

civil damages. Any insurance company or

fraudulent claim containing any false or misleading

agent of an insurance company who knowingly

provides false, incomplete, or misleading facts or

information is guilty of insurance fraud and may be

subject to fines and confinement in prison.

information to a policyholder or claimant for the

purpose of defrauding or attempting to defraud

Alabama –

Any person who knowingly presents a

the policyholder or claimant with regard to a

false or fraudulent claim for payment of a loss or

settlement or award payable from insurance

benefit or who knowingly presents false information

proceeds shall be reported to the Colorado

in an application for insurance is guilty of a crime and

division of insurance within the department of

may be subject to restitution, fines, or confinement in

regulatory agencies.

prison, or any combination thereof.

Delaware –

Any person who knowingly, and with

Alaska –

A person who knowingly and with intent to

intent to injure, defraud or deceive any insurer, files a

injure, defraud, or deceive an insurance company files

statement of claim containing any false, incomplete,

a claim containing false, incomplete, or misleading

or misleading information is guilty of a felony.

information may be prosecuted under state law.

District of Columbia –

WARNING: It is a crime to

Arizona -

For your protection Arizona law

provide false or misleading information to an insurer

requires the following statement to appear

for the purpose of defrauding the insurer or any

on this form. Any person who knowingly

other person. Penalties include imprisonment and/

presents a false or fraudulent claim for

or fines. In addition, an insurer may deny insurance

payment of a loss is subject to criminal and

benefits if false information materially related to a

civil penalties.

claim was provided by the applicant.

Arkansas, Louisiana, Rhode Island and West

Florida –

Any person who knowingly and with intent

Virginia –

Any person who knowingly presents a false

to injure, defraud or deceive any insurance company

or fraudulent claim for payment of a loss or benefit or

files a statement of claim or an application containing

knowingly presents false information in an application

any false, incomplete, or misleading information is

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

guilty of a felony of the third degree.

fines and confinement in prison.

Idaho –

Any person who knowingly, and with intent

California –

For your protection California law requires

to defraud or deceive any insurance company, files

the following to appear on this form: Any person

a statement containing any false, incomplete, or

who knowingly presents false or fraudulent claim for

misleading information is guilty of a felony.

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

subject to fines and confinement in state prison.

Indiana –

A person who knowingly and with intent to

defraud an insurer files a statement of claim containing

Colorado –

It is unlawful to knowingly provide

any false, incomplete, or misleading information

false, incomplete, or misleading facts or

commits a felony.

information to an insurance company for

the purpose of defrauding or attempting to

defraud the company. Penalties may include

Fraud 2-16

Hospital Indemnity Claim Form - Gtl Page 4

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