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9Life Insurance Claim Form
Claimant’s Statement
FRAUD WARNINGS
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 a 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 payable 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 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: A person who knowingly and with intent to injure, defraud or deceive any 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.
Kentucky: 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.
Maine, Tennessee, Virginia and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purposes 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: Any 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 R.S.A.
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.
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 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.
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GR-CLAIM-FRAUD
(04/13) Fs
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