Cirseiu House Staff Benefits Plan Direct Reimbursement Claim Form - 2009 Page 3
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3FRAUD STATEMENT
Any person who knowingly and with intent to defraud and deceive any insurance company submits
an insurance application or statement of claim containing any false, incomplete or misleading
information may be subject to civil or criminal penalties, depending upon state law.
In Florida, any person who knowingly and with intent to injure, defraud or deceive any insurer files
a statement of claim or an insurance application containing any false, incomplete or misleading
information is guilty of a felony of the third degree.
In New Jersey, any person who includes any false or misleading information on an application for
insurance is subject to criminal and civil penalties.
In New York, applicants for Accident and Health Insurance: 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.
In Kentucky and Pennsylvania, 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.
In Tennessee, state law stipulates that it is a crime to knowingly provide false, incomplete or
misleading information to an insurance company for the purpose of defrauding the company. Penalties
include imprisonment, fines and denial of insurance benefits.
For Washington, D.C. residents:
WARNING: It is a crime to provide false or misleading information to an insurer for the purpose 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.
SC00015
4/23/09
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