Critical Illness Insurance Claim Form - Metlife Form (Page 4 of 8) in pdf

Oregon and Vermont: Any person who knowingly

Texas: Any person who knowingly presents a false or

presents a false statement of claim for insurance may be

fraudulent claim for the payment of a loss is guilty of a

guilty of a criminal offense and subject to penalties under

crime and may be subject to fines and confinement in

state law.

state prison.

Puerto Rico: Any person who knowingly and with the

Pennsylvania and all other states: Any person who

intention to defraud includes false information in an

knowingly and with intent to defraud any insurance

application for insurance or files, assists or abets in the

company or other person files an application for insurance

filing of a fraudulent claim to obtain payment of a loss or

or statement of claim containing any materially false

other benefit, or files more than one claim for the same

information, or conceals for the purpose of misleading,

loss or damage, commits a felony and if found guilty shall

information concerning any fact material thereto commits

be punished for each violation with a fine of no less than

a fraudulent insurance act, which is a crime and subjects

five thousand dollars ($5,000), not to exceed ten thousand

such person to criminal and civil penalties.

dollars ($10,000); or imprisoned for a fixed term of three

(3) years, or both. If aggravating circumstances exist, the

fixed jail term may be increased to a maximum of five (5)

years; and if mitigating circumstances are present, the jail

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

SECTION 6 - Certification & Signature

By signing below, I acknowledge:

• All information I have given is true and complete to the best of my knowledge and belief.

• I have read the applicable Fraud Warning(s) provided in this form. New York Residents: 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 claim for each such violation.

Under penalty of perjury, I certify:

1. That the number shown on this form is my correct taxpayer identification / social security number; and

2. That I am not subject to IRS required backup withholding as a result of failure to report all interest or

dividend income; and

3. I am a U.S. citizen, or a U.S. resident for tax purposes.

Please note: If item 2 or 3 above is not true, cross out the applicable item(s). The IRS does not require your consent

to any provision of this document other than the certification to avoid backup withholding.

Name of Claimant (Please Print)

Social Security Number

Signature of Claimant or Authorized Representative

Date (mm/dd/yyyy)

If signed by Authorized Representative, describe your authority and provide documentation.

(e.g., guardian, conservator, power of attorney, etc.)

CII-CLM-GENERIC-NW (05/15) Fs

Page 4 of 8

Critical Illness Insurance Claim Form - Metlife Form Page 4

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