Direct Reimbursement Claim Form (Page 2 of 2) in pdf

Direct Reimbursement Claim Form Page 2

FRAUD STATEMENT

Any person who knowingly and with intent to defraud and deceive any insurance company submits

an insurance application or statement of claim containing any false, incomplete or misleading

information may be subject to civil or criminal penalties, depending upon state law.

In Florida, any person who knowingly and with intent to injure, defraud or deceive any insurer files

a statement of claim or an insurance application containing any false, incomplete or misleading

information is guilty of a felony of the third degree.

In New Jersey, any person who includes any false or misleading information on an application for

insurance is subject to criminal and civil penalties.

In New York, applicants for Accident and Health Insurance: 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.

In Kentucky and 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.

In Tennessee, state law stipulates that 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.

Direct Reimbursement Claim Form Page 2