Fillable Form Gc-1652 - Commercial Prescription Drug Claim Form (Page 2 of 2) in pdf

Misrepresentation

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

Attention Alabama Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who

knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or

confinement in prison, or any combination thereof. Attention Arkansas, District of Columbia, Rhode Island and West Virginia

Residents: 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. Attention California

Residents: For your protection California law requires notice of the following to appear on this form: Any person who knowingly

presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state

prison. Attention Colorado Residents: 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. Attention Florida Residents: 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. Attention Kansas Residents: Any person who knowingly and with intent to injure,

defraud or deceive any insurance company or other person submits an enrollment form for insurance or statement of claim containing any

materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto may have violated

state law. Attention Kentucky Residents: Any person who knowingly and with intent to defraud any insurance company or other person

files a 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. Attention Louisiana Residents: 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 is

guilty of a crime and may be subject to fines and confinement in prison. Attention Maine and Tennessee Residents: It is a crime to

knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company.

Penalties may include imprisonment, fines, or denial of insurance benefits. Attention Maryland Residents: 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. Attention Missouri Residents: 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, denial of insurance and civil damages, as determined by a court of law. Any person who

knowingly and with intent to injure, defraud or deceive an insurance company may be guilty of fraud as determined by a court of law.

Attention New Jersey Residents: Any person who includes any false or misleading information on an application for an insurance policy

or knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. Attention

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 be subject to a civil penalty not to

exceed five thousand dollars and the stated value of the claim for each violation. Attention North Carolina Residents: Any person who

knowingly and with intent to injure, defraud or deceive 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 may be a crime and subjects such person to criminal and civil penalties.

Attention Ohio Residents: Any person who, with 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 is guilty of insurance fraud. Attention Oklahoma Residents:

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. Attention Oregon Residents: Any

person who with intent to injure, defraud, or deceive any insurance company or other person submits an enrollment form for insurance or

statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact

material thereto may have violated state law. Attention Pennsylvania 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 subjects such person to criminal and civil penalties. Attention Puerto Rico Residents: Any person who knowingly and with

the intention to defraud includes false information in an application for insurance or file, assist or abet in the filing of a fraudulent claim to

obtain payment of a loss or other benefit, or files more than one claim for the same loss or damage, commits a felony and if found guilty

shall be punished for each violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten thousand 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. Attention Texas Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company

or other person files an application for insurance or statement of claim containing any intentional misrepresentation of material fact or

conceals, for the purpose of misleading, information concerning any fact material thereto may commit a fraudulent insurance act, which

may be a crime and may subject such person to criminal and civil penalties. Attention Vermont Residents: Any person who knowingly

and with intent to injure, defraud or deceive 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 may be a crime and may subject such person to criminal and civil penalties. Attention

Virginia Residents: Any person who knowingly and with intent to injure, defraud or deceive 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 act, which is a crime and subjects such person to criminal and civil

penalties. Attention Washington Residents: 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.

GC-1652 (3-14) A

Form Gc-1652 - Commercial Prescription Drug Claim Form Page 2

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