Form Twm-Cancerclaim-072710 - Cancer/specified Disease Claim Package Page 3
Download a blank fillable Form Twm-Cancerclaim-072710 - Cancer/specified Disease Claim Package in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Twm-Cancerclaim-072710 - Cancer/specified Disease Claim Package with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4R
F
W
S
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 MARYLAND: Any person who knowingly and
FOR RESIDENTS OF ARIZONA: For your protection, Arizona
willfully presents a false or fraudulent claim for payment of a loss or benefit
law requires the following statement to appear on this form.
or who knowingly and willfully presents false information in an application
Any person who knowingly presents a false or fraudulent
for insurance is guilty of a crime and may be subject to fines and
claim for payment of a loss is subject to criminal and civil
confinement 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 JERSEY: Any person who knowingly files a
company who knowingly provides false, incomplete, or misleading facts or
statement of claim containing any false or misleading information is
information to a policyholder or claimant for the purpose of defrauding or
subject to criminal and civil penalties.
attempting to defraud the policyholder or claimant with regard to a
___________________________________________________________
Claimant’s signature
Date
settlement or award payable from the insurance proceeds shall be
reported to the Colorado Division of Insurance within the department of
FOR RESIDENTS OF OKLAHOMA: Any person who knowingly, and with
regulatory agencies.
intent to injure, defraud or deceive any insurer, makes any claim for the
___________________________________________________________
proceeds of an insurance policy containing any false, incomplete or
Claimant’s signature
Date
misleading information is guilty of a felony.
___________________________________________________________
FOR RESIDENTS OF DELAWARE, IDAHO or INDIANA: Any person
who knowingly, and with intent to injure, defraud or deceive any insurer,
Claimant’s signature
Date
files a statement of claim containing any false, incomplete or misleading
FOR RESIDENTS OF PUERTO RICO: Any person who knowingly and
information is guilty of a felony.
with the intention of defrauding presents false information in an insurance
___________________________________________________________
application, or presents, helps, or causes the presentation of a fraudulent
Claimant’s signature
Date
claim for the same damage or loss, shall incur a felony and, upon
FOR RESIDENTS OF DISTRICT OF COLUMBIA, LOUISIANA or
conviction, shall be sanctioned for each violation with the penalty of a fine
RHODE ISLAND:
Any person who knowingly presents a false or
of not less than five thousand (5,000) dollars and not more than ten
fraudulent claim for payment of a loss or benefit or who knowingly
thousand (10,000) dollars, or a fixed term of imprisonment for three (3)
presents false information in an application for insurance is guilty of a
years, or both penalties. Should aggravating circumstances are present,
crime and may be subject to fines and confinement in prison.
the penalty thus established may be increased to a maximum of five (5)
___________________________________________________________
years, if extenuating circumstances are present, it may be reduced to a
Claimant’s signature
Date
minimum of two (2) years.
FOR RESIDENTS OF FLORIDA: Any person who knowingly and with
___________________________________________________________
intent to injure, defraud, or deceive any insurer files a statement of claim or
Claimant’s signature
Date
an application containing any false, incomplete, or misleading information
FOR RESIDENTS OF ALL OTHER STATES: Any person who knowingly,
is guilty of a felony of the third degree.
and with intent to injure, defraud or deceive any insurance company or
___________________________________________________________
other person files an application for insurance or statement of claim
Claimant’s signature
Date
containing any materially false information or conceals for the purpose of
FOR RESIDENTS OF HAWAII: For your protection, Hawaii law requires
misleading, information concerning any fact material thereto commits a
you to be informed that presenting a fraudulent claim for payment of a loss
fraudulent insurance act, which is a crime and subjects such person to
or benefit is a crime punishable by fines or imprisonment, or both
criminal and civil penalties.
___________________________________________________________
__________________________________________________________
Claimant’s signature
Date
Claimant’s signature
Date
TWM-CancerClaim-072710
Page 3 of 4
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Ca-2 - Notice Of Occupational Disease And Claim For Compensation - United States Department Of Labor, Office Of Workers Compensation Programs
Legal
Form Llp 2007 - Foreign Limited Liability Partnership Registration Package Of Forms With Instructions - State Of Nevada
Legal
Form Cg-5/6-att - Schedule B - Cigarette Packages Stamped During The Month - State Of New York
Financial
Related Categories
Parent category: Business