Form Teb-Adbltchome-072413 - Accelerated Death Benefit For Long Term Care Claim Form Page 3
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W
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EQUIRED
RAUD
ARNING
TATEMENTS
Claimants are required to acknowledge receipt of fraud warnings. Please refer to the fraud warning statement for your state as indicated below. Sign,
date, and return with claim documents.
FOR RESIDENTS OF ALASKA or TEXAS: A person who knowingly and
FOR RESIDENTS OF MAINE, TENNESSEE or VIRGINIA: It is a crime to
with intent to injure, defraud, or deceive an insurance company files a
knowingly provide false, incomplete or misleading information to an
claim containing false, or misleading information may be prosecuted under
insurance company for the purpose of defrauding the company. Penalties
state law.
include imprisonment, fines, and denial of insurance benefits.
___________________________________________________________
___________________________________________________________
Claimant’s signature
Date
Claimant’s signature
Date
FOR RESIDENTS OF ARIZONA: For your protection, Arizona
FOR RESIDENTS OF MARYLAND: Any person who knowingly or willfully
presents a false or fraudulent claim for payment of a loss or benefit or who
law requires the following statement to appear on this form.
knowingly or willfully presents false information in an application for
Any person who knowingly presents a false or fraudulent
insurance is guilty of a crime and may be subject to fines and confinement
claim for payment of a loss is subject to criminal and civil
in prison.
penalties.
___________________________________________________________
___________________________________________________________
Claimant’s signature
Date
Claimant’s signature
Date
FOR RESIDENTS OF MINNESOTA: A person who files a claim with intent
to defraud or help commit a fraud against an insurer is guilty of a crime.
FOR RESIDENTS OF CALIFORNIA: For your protection California law
___________________________________________________________
requires the following to appear on this form. Any person who knowingly
Claimant’s signature
Date
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.
FOR RESIDENTS OF NEW HAMPSHIRE: Any person who, with a
___________________________________________________________
purpose to injure, defraud or deceive any insurance company, files a
Claimant’s signature
Date
statement of claim containing any false, incomplete or misleading
information is subject to prosecution and punishment for insurance fraud,
FOR RESIDENTS OF COLORADO: It is unlawful to knowingly provide
as provided by RSA 638:20.
false, incomplete or misleading facts or information to an insurance
___________________________________________________________
company for the purpose of defrauding or attempting to defraud the
Claimant’s signature
Date
company. Penalties may include imprisonment, fines, denial of insurance
and civil damages. Any insurance company or agent of an insurance
FOR RESIDENTS OF NEW YORK: Any person who knowingly and with
company who knowingly provides false, incomplete, or misleading facts or
intent to defraud any insurance company or other person files an
information to a policyholder or claimant for the purpose of defrauding or
application for insurance or statement of claim containing any materially
attempting to defraud the policyholder or claimant with regard to a
false information, or conceals for the purpose of misleading, information
settlement or award payable from the insurance proceeds shall be
concerning any fact material thereto, commits a fraudulent act, which is a
reported to the Colorado Division of Insurance within the department of
crime and shall be subject to a civil penalty not to exceed five thousand
regulatory agencies.
dollars and the stated value of the claim for each such violation.
___________________________________________________________
___________________________________________________________
Claimant’s signature
Date
Claimant’s signature
Date
FOR RESIDENTS OF DELAWARE, IDAHO, INDIANA or OKLAHOMA:
Any person who knowingly, and with intent to injure, defraud or deceive
FOR RESIDENTS OF PUERTO RICO: Any person who knowingly and
any insurer, files a statement of claim containing any false, incomplete or
with the intention of defrauding presents false information in an insurance
misleading information is guilty of a felony.
application, or presents, helps, or causes the presentation of a fraudulent
___________________________________________________________
claim for the same damage or loss, shall incur a felony and, upon
Claimant’s signature
Date
conviction, shall be sanctioned for each violation with the penalty of a fine
FOR RESIDENTS OF DISTRICT OF COLUMBIA, LOUISIANA or
of not less than five thousand (5,000) dollars and not more than ten
RHODE ISLAND:
Any person who knowingly presents a false or
thousand (10,000) dollars, or a fixed term of imprisonment for three (3)
fraudulent claim for payment of a loss or benefit or who knowingly
years, or both penalties. Should aggravating circumstances are present,
presents false information in an application for insurance is guilty of a
the penalty thus established may be increased to a maximum of five (5)
crime and may be subject to fines and confinement in prison.
years, if extenuating circumstances are present, it may be reduced to a
___________________________________________________________
minimum of two (2) years.
Claimant’s signature
Date
___________________________________________________________
FOR RESIDENTS OF FLORIDA: Any person who knowingly and with
Claimant’s signature
Date
intent to injure, defraud, or deceive any insurer files a statement of claim
FOR RESIDENTS OF ALL OTHER STATES AND TERRITORIES: Any
or an application containing any false, incomplete, or misleading
person who knowingly, and with intent to injure, defraud or deceive any
information is guilty of a felony of the third degree.
insurance company or other person files an application for insurance or
___________________________________________________________
statement of claim containing any materially false information or conceals
Claimant’s signature
Date
for the purpose of misleading, information concerning any fact material
FOR RESIDENTS OF HAWAII: For your protection, Hawaii law requires
thereto commits a fraudulent insurance act, which is a crime and subjects
you to be informed that presenting a fraudulent claim for payment of a loss
such person to criminal and civil penalties.
or benefit is a crime punishable by fines or imprisonment, or both
__________________________________________________________
___________________________________________________________
Claimant’s signature
Date
Claimant’s signature
Date
TEB-ADBLTCHome-072413
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