Fillable Vision Benefits Claim Form - Avesis (Page 2 of 2) in pdf

INSURANCE FRAUD STATEMENTS

FRAUD NOTICE: For the states of AL, AZ, AR, CA,

Georgia Residents: Any person who with intent to

Oregon Residents: Any person who with intent to

CO, DE, DC, FL, GA, IN, KS, KY, LA, MD, ME, NC,

defraud or knowing that he/she is facilitating a fraud

NE, NJ, NM, OK, OR, PA, RI, TN, TX, VA, VT, and

against an insurer, submits an application or files a

WV, please refer to the following fraud notices:

claim containing a false or deceptive statement may

be guilty of insurance fraud.

Alabama Residents: Any person who knowingly

presents a false or fraudulent claim for payment of loss

Indiana Residents: A person who knowingly and with

Pennsylvania Residents: Any person who knowingly

or benefit or who knowingly presents false information

intent to defraud an insurer files a statement of claim

and with intent to defraud any insurance company or

in an application for insurance is guilty of a crime and

containing any false, incomplete, or misleading

other person files an application for insurance or

may be subject to restitution, fines or confinement in

information commits a felony.

statement of claim containing any materially false

prison, or any combination thereof.

information or conceals, for the purpose of misleading,

Kansas Residents: Any person who with intent to

information concerning any fact material thereto

Arizona Residents: For your

defraud or knowing that he or she is facilitating a

commits a fraudulent insurance act, which is a crime

fraud against an insurer, submits an application or

and subjects such person to criminal and civil

protection, Arizona law requires

files a claim containing a false or deceptive statement

penalties.

may be guilty of insurance fraud as determined by a

the following statement to

court of law.

Rhode Island Residents: Any person who knowingly

presents a false or fraudulent claim for payment of

appear on this form: Any

Kentucky Residents: Any person who knowingly

loss or benefit or knowingly presents false information

person who knowingly presents

and with intent to defraud any insurance company or

in an application for insurance is guilty of a crime and

other person files a statement of claim containing any

may be subject to fines and confinement in prison.

a false or fraudulent claim for

materially false information or conceals, for the

purpose of misleading, information concerning any

Tennessee Residents: It is a crime to knowingly

payment of a loss is subject to

fact material thereto commits a fraudulent insurance

provide false, incomplete or misleading information to

criminal and civil penalties.

act, which is a crime.

an insurance company for the purpose of defrauding

the company. Penalties may include imprisonment,

Louisiana Residents: Any person who knowingly

fines and denial of insurance benefits.

Arkansas Residents: Any person who knowingly

presents a false or fraudulent claim for payment of

presents a false or fraudulent claim for payment of loss

loss or benefit or knowingly presents false information

Texas Residents: Any person who knowingly presents

or benefit or knowingly presents false information in an

in an application for insurance is guilty of a crime and

a false or fraudulent claim for payment of a loss is

application for insurance is guilty of a crime and may

may be subject to fines and confinement in prison.

guilty of a crime and may be subject to fines and

be subject to fines and confinement in prison.

confinement in state prison.

Maryland Residents: Any person who knowingly and

California Residents: For your protection, California

willfully presents a false or fraudulent claim for

Vermont Residents: Any person who with intent to

law requires the following to appear on this form: Any

payment of a loss or benefit or who knowingly and

defraud or knowing that he/she is facilitating a fraud

person who knowingly presents false or fraudulent

willfully presents false information in an application for

against an insurer, submits an application or files a

claim for the payment of a loss is guilty of a crime and

insurance is guilty of a crime and may be subject to

claim containing a false or deceptive statement may

may be subject to fines and confinement in state

fines and confinement in prison.

be guilty of insurance fraud.

prison.

Maine Residents: It is a crime to knowingly provide

Virginia Residents: It is a crime to knowingly provide

Colorado Residents: It is unlawful to knowingly

false, incomplete or misleading information to an

provide false, incomplete, or misleading facts or

insurance company for the purpose of defrauding the

information to an insurance company for the purpose

company. Penalties may include imprisonment, fines

company. Penalties include imprisonment, fines and

of defrauding or attempting to defraud the company.

or a denial of insurance benefits.

denial of insurance benefits.

Penalties may include imprisonment, fines, denial of

insurance and civil damages. Any insurance company

Nebraska Residents: Any person who, with intent to

West Virginia Residents: Any person who knowingly

or agent of an insurance company who knowingly

defraud or knowing that he or she is facilitating a

presents a false or fraudulent claim for payment of

provides false, incomplete, or misleading facts or

fraud against an insurer, submits an application or

loss or benefit or knowingly presents false information

information to a policyholder or claimant for the

files a claim containing a materially false or deceptive

in an application for insurance is guilty of a crime and

purpose of defrauding or attempting to defraud the

statement is guilty of insurance fraud.

may be subject to fines and confinement in prison.

policyholder or claimant with regard to a settlement or

award payable from insurance proceeds shall be

New Jersey Residents: Any person who knowingly

reported to the Colorado Division of Insurance within

files a statement of claim containing any false or

the Department of Regulatory Agencies.

misleading information is subject to criminal and civil

penalties.

Delaware Residents: Any person who knowingly, and

with intent to injure, defraud or deceive any insurer,

New Mexico Residents: Any person who knowingly

files a statement of claim containing any false,

presents a false or fraudulent claim for payment of a

incomplete or misleading information is guilty of a

loss or benefit or knowingly presents false information

felony.

in an application for insurance is guilty of a crime and

may be subject to civil fines and criminal penalties.

District of Columbia Residents: WARNING: It is a

crime to provide false or misleading information to an

North Carolina Residents: Any person with the

insurer for the purpose of defrauding the insurer or any

intent to injure, defraud, or deceive an insurer or

other person. Penalties include imprisonment and/or

insurance claimant is guilty of a crime (Class H

fines. In addition, an insurer may deny insurance

felony) which may subject the person to criminal and

benefits if false information materially related to a claim

civil penalties.

was provided by the applicant.

Oklahoma Residents: WARNING: Any person who

Florida Residents: Any person who knowingly and

knowingly, and with intent to injure, defraud or

with intent to injure, defraud, or deceive any insurer

deceive any insurer, makes any claim for the

files a statement of claim or an application containing

proceeds of an insurance policy containing any false,

any false, incomplete, or misleading information is

incomplete or misleading information is guilty of a

guilty of a felony of the third degree.

felony.

Vision Benefits Claim Form - Avesis Page 2

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