Fillable Beneficiary Claim Form (Page 2 of 3) in pdf

BENEFICIARY CLAIM FORM

5. FRAUD WARNING STATEMENTS

Any person who knowingly and with intent to defraud or injure any insurance company or other person files a statement of claim

containing any materially false, incomplete or misleading information or omits or conceals information concerning any fact

material thereto, commits a fraudulent insurance act, which may result in criminal penalties, including fines and/or imprisonment.

under penalty of perjury, i certify that the information supplied is true, correct, and complete.

STATE SPECIFIC LANGUAGE

Alabama, Arkansas, Louisiana, Maryland, New Mexico, Rhode Island, and West Virginia: Any person who

knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information

in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement in prison, or any

combination thereof.

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 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 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: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a

statement of claim containing any false, incomplete or misleading information is guilty of a felony.

D.C.: WArninG: it is a crime to provide false or misleading information to an insurer for the purposes 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: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or

an application containing any 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.

Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

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 nH rev. Stat. Ann. §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.

New York: 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 a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Ohio: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an

application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

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.

200

09.11.13

AmericAn equity inVeStment Life inSurAnce compAny • p .o. Box 527 • peLL city, AL 35125-0527 • 877-508-9888

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Beneficiary Claim Form Page 2

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