Fillable Express Wellness Benefit Claim Form (Page 4 of 4) in pdf

EXPRESS WELLNESS BENEFIT CLAIM FORM

The Benefits Center

P.O. Box 100158, Columbia, SC 29202-3158

Toll-free: 1-800-635-5597 Fax: 1-800-447-2498

Call toll-free Monday through Friday, 8 a.m. to 8 p.m. Eastern Time.

CLAIM FRAUD STATEMENTS

Fraud Warning for New Jersey Residents

For your protection, New Jersey law requires the following to appear on this claim form:

Any person who knowingly and with intent to defraud any insurance company or other persons, 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, subject to criminal prosecution and civil penalties.

Fraud Warning for New York Residents

For your protection, New York law requires the following to appear on this claim form:

Any person who knowingly and with the 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 a civil penalty not to exceed five thousand dollars and the

stated value of the claim for each such violation.

Fraud Warning for Pennsylvania Residents

For your protection, Pennsylvania law requires the following to appear on this claim form:

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.

Fraud Warning for Puerto Rico Residents

For your protection, Puerto Rico law requires the following to appear on this claim form:

Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents,

helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than

one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation with the

penalty of a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term

of imprisonment for three (3) years, or both penalties. If aggravating circumstances are present, 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 minimum of two (2)

years.

CL-1144 (08/14)

Express Wellness Benefit Claim Form Page 4