Fillable Proof Of Death Claim Form - Life Insurance Benefits (Page 3 of 8) in pdf

Standard Insurance Company

Life Insurance Benefits

Life Benefits Department

Claim Form Fraud Notices

PO Box 2800 Portland OR 97208 800.628.8600 Tel

Some states require us to provide the following information to you:

ALABAMA, MARYLAND AND RHODE ISLAND 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.

CALIFORNIA RESIDENTS

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 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 the 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 RESIDENTS

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 RESIDENTS

Any person who knowingly and with intent to injure, defraud or deceive an insurance company, files a statement of claim or an

application containing false, incomplete or misleading information is guilty of a felony of the third degree.

NEW JERSEY RESIDENTS

Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and

civil penalties.

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 also be subject to civil

penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

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.

ALL OTHER RESIDENTS

Some states require us to inform you that any person who knowingly and with intent to injure, defraud or

deceive an insurance company, or other person, files a statement containing false or misleading information

concerning any fact material hereto commits a fraudulent insurance act which is subject to civil and/or

criminal penalties, depending upon the state. Such actions may be deemed a felony and substantial fines

may be imposed.

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SI 1794

(8/16)

Proof Of Death Claim Form - Life Insurance Benefits Page 3

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