Fillable Form Amr Di 0917 - Disability Claim Employee Statement (Page 11 of 12) in pdf

Disability Claim Attending Physician Statement (Continued)

Name of Employee:

Social Security Number:

Fraud Warning:

Before signing this claim form, please read the warning for the state where you reside and for the state where the

insurance policy under which you are claiming a benefit was issued.

Alabama, Arkansas, District of Columbia, Louisiana, Massachusetts, Minnesota, New Mexico, Ohio, Rhode Island

and West Virginia – 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.

Alaska – A person who knowingly and with intent to injure, defraud or deceive an insurance company files a claim

containing false, incomplete or misleading information may be prosecuted under state law.

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 loss is

subject to criminal and civil penalties.

California – For your protection, California law requires 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.

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 from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of

Regulatory Agencies.

Delaware, Idaho, Indiana and Oklahoma – WARNING: Any person who knowingly and with the 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.

Florida – Any person who knowingly and with intent to injure, defraud or deceive any insurance company files

a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a

felony of the third degree.

Kentucky – Any person who knowingly and with the 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.

Maine, Tennessee, Virginia and 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 may include

imprisonment, fines or a denial of insurance benefits.

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.

New Hampshire – A person who, with a purpose to injure, defraud or deceive any insurance company, files a

statement of claim containing any false, incomplete or misleading information is subject to prosecution and

punishment for insurance fraud, as provided in RSA 638:20.

New Jersey – Any person who knowingly files a statement of claim containing any false or misleading information

is subject to criminal and civil penalties.

Oregon and Vermont – Any person who knowingly presents a false statement of claim for insurance may be guilty

of a criminal offense and subject to penalties under state law.

Page 11 of 12

AMR DI 0917 (02/14) Fs

Form Amr Di 0917 - Disability Claim Employee Statement Page 11

Related Articles

Related forms

Related Categories