Maternity Disability Claim Form (Page 4 of 4) in pdf

NOTICE IN 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.

NOTICE IN OREGON: Any person who makes intentional misstatement that is material to the risk may be found guilty

of insurance fraud by a court of law.

NOTICE IN 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.

NOTICE IN PUERTO RICO: Any person who knowingly and with the intention to defraud includes false information in

an application for insurance or file, assist or abet in the filing of a fraudulent claim to obtain payment of a loss or other

benefit, or files more than one claim for the same loss or damage, commits a felony and if found guilty shall be

punished for each violation with a fine of no less than five thousands dollars ($5,000), not to exceed ten thousands

dollars ($10,000); or imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the

fixed jail term may be increased to a maximum of five (5) years; and if mitigating circumstances are present, the jail

term may be reduced to a minimum of two (2) years.

NOTICE IN TENNESSEE AND WASHINGTON: 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.

NOTICE IN TEXAS: Any person who knowingly 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.

NOTICE IN WEST VIRGINIA AND RHODE ISLAND: Any person who knowingly presents a false or fraudulent claim

for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a

crime and may be subject to fines and confinement in prison.

ABJ16702-4

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Maternity Disability Claim Form Page 4