Fillable Form Amr Di 0917 - Disability Claim Employee Statement (Page 8 of 12) in pdf

Form Amr Di 0917 - Disability Claim Employee Statement Page 8

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Disability Claim Statement (Continued)

Name of Employee:

Social Security Number:

Fraud Warning

(continued)

Puerto Rico – Any person who knowingly and with the intention to defraud includes false information in an

application for insurance or files, assists or abets 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.

Texas – 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.

Pennsylvania and all other states – Any person who knowingly and with intent to defraud any insurance company

or other person files an application for insurance or a statement of claim containing any materially false information

or conceals for the purpose of misleading, information concerning a fact material thereto commits a fraudulent

insurance act, which is a crime and subjects such person to criminal and civil penalties.

Employer’s Authorized Representative

Supervisor’s Authorization Signature

Title

Phone #

mm/dd/yy

Signature

Date

Page 8 of 12

AMR DI 0917 (02/14) Fs

Form Amr Di 0917 - Disability Claim Employee Statement Page 8

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