Fillable Form C-5082 - Proofs Of Death-Claimant'S Statement (Page 3 of 3) in pdf

Important Notice

In some states we are required to advise you of the following: Any person who, with intent to defraud or knowing that he

is facilitating a fraud against an insurer, submits an application containing a false or deceptive statement may be guilty of

insurance fraud.

Arizona – “For your protection Arizona law requires the following statement to appear on this form. Any

person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal

and civil penalties.”

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.

District of Columbia – Warning: It is a crime to provide false or misleading information to an insurer for the purpose of

defrauding the 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.

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.

Maryland – "Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or

who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject

to fines and confinement in prison."

Massachusetts – 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 state prison.

New Jersey – Any person who includes any false or misleading information on an application for an insurance policy 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.

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.

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 sub-

jects such person to criminal and civil penalties.

Puerto Rico – Any person who, knowingly and with the intent to defraud, presents false information in an insurance request

form, or who presents, helps or has presented a fraudulent claim for the payment of a loss or other benefit, presents more

than one claim for the same damage or loss, will incur a felony, and upon conviction will be penalized for each violation with a

fine no less than five thousand (5,000) dollars nor more than ten thousand (10,000) dollars, or imprisonment for a fixed term of

three (3) years, or both penalties. If aggravated circumstances prevail, the fixed established imprisonment may be increased

to a maximum of five (5) years; if attenuating circumstances prevail, it may be reduced to a minimum of two (2) years.

Rhode Island – 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.

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.

Virginia – Any person who, with the 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 may have violated state law.

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.

In All Other States – Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer

submits an application containing a false or deceptive statement may be guilty of insurance fraud.

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Form C-5082 - Proofs Of Death-Claimant'S Statement Page 3

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