Page 3
Internal Use
Category
Code
VPC
F
Office Key
Code
039
Deceased Information
Name (Last, First, Middle Initial)
Social Security Number
Internal Use:
Category Code:
LSTD
Office Key
Code: 128
H. Employer's Authorized Representative
Any person wh o knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for
insurance or statement of claim containing any m aterially f alse information or conceals, for th e 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.
Attention Alabama Residents: 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. Attention Arkansas, District of Columbia, Rhode Island and West Virginia Residents: Any person
who k nowingly 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. Attention California Residents: For your p rotection,
California law requires notice of the following to appear on this form: 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. Attention Colorado R esidents: It is
unlawful to knowingly provide false, in complete, o r misleading facts o r in formation to a n ins urance company for the purpose o f defrauding or
attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance
company or a gent of an insurance company who knowingly provides false, i ncomplete, o r m isleading facts or information to a p olicyholder or
claimant for the purpose o f de frauding or attempting to d efraud the po licyholder o r claimant w ith regard to a s ettlement o r aw ard payable from
insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. Attention Florida
Residents: Any person who knowingly and w ith intent to injure, defraud, or deceive any insurer files a statement of claim or an application
containing any false, incomplete o r misleading information is gu ilty of a felony of the third deg ree. Attention Kansas Residents: Any person
who knowingly and with in tent to injure, defraud o r d eceive any insurance company or o ther person submits an e nrollment form for insurance
or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact
material thereto may have violated state la w. Attention Kentucky Re sidents: Any person who knowingly and with intent to defraud any
insurance c ompany or other pe rson files a statement of c laim containing any materially false information or conceals, for the purpose of
misleading, in formation co ncerning a ny fact material thereto commits a fraudulent i nsurance act, which i s a crime. Attention Louisiana
Residents: Any person who knowingly presents a false o r fraudulent c laim f or paymen t of a loss o r b enefit or knowingly presents false
information in an application is guilty of a crime and may be subject to fines and confinement in prison. Attention Maine and Tennessee
Residents: It i s a crime to knowingly provide false, in complete o r misleading information to an insurance company for the pu rpose o f
defrauding the c ompany. Penalties m ay include imprisonment, fines or denial of insurance ben efits. Attention Maryland Residents: Any
person who knowingly or willfully presents a false or fraudulent claim for payment o f a lo ss o r be nefit or who knowingly or w illfully presents
false in formation in an application for insurance is guilty of a cr ime a nd m ay be subject to fines and confinement in p rison. Attention Missouri
Residents: It i s a crime to knowingly provide false, in complete, o r misleading information to an insurance company for the pu rpose o f
defrauding the company. Penalties include imprisonment, fines, denial of insurance and civil damages, as determined by a court of law. Any
person who knowingly and with intent to injure, defraud or deceive an insurance company may be guilty of fraud as determined by a court of
law. Attention New Jersey Residents: Any person who i ncludes any f alse or misleading information on an application for an insurance policy
or knowingly fi les a statement of claim containing any f alse or mis leading information is subject to criminal and civil penalties. Attention North
Carolina Residents: Any person who knowingly and with intent to injure, defraud or deceive 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 may be a crime and subjects such person to
criminal and civil penalties. Attention Ohio Residents: A ny person who, with intent to de fraud or knowing he is f acilitating a fraud aga inst an
insurer, submits an application or files a claim containing a false or deceptive stat ement is guilty of insurance fraud. Attention Oklahoma
Residents: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any c laim for the
proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Attention Oregon Residents:
Any person who with intent to injure, defraud or deceive any insurance company or other person submits an enrollment form for insurance or
statement of c laim containing any ma terially false in formation o r conceals for the purpose o f misleading, in formation concerning any fact
material thereto may have violated state la w. Attention Pennsylvania Residents: Any person who knowingly and with intent to d efraud a ny
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. Attention Puerto Rico Residents: Any person who knowingly and with the intention
to d efraud includes false in formation in an app lication for in surance or file, assist or abet i n the filing o f a fraudulent c laim 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 w ith a fine o f n o less than five thousand d ollars ($5,000), not to ex ceed ten thousand do llars ( $10,000); o r im prisoned for a f ixed
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. Attention Texas R esidents: Any person
who knowingly and with in tent to injure, defraud o r d eceive any insurance company or o ther person files an ap plication for in surance or
statement of claim containing any intentional misrepresentation of material fact or conceals, for the purpose of misleading, information
concerning any fact material thereto may commit a fraudulent insurance a ct, w hich may be a c rime and may subject such person to criminal
and civil penalties. Attention Vermont Residents: Any person who knowingly and with intent to injure, defraud or deceive 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 o f m isleading, in formation co ncerning a ny fact material thereto commits a fraudulent i nsurance act, which m ay be a crime and
may subject such person to criminal and civil penalties. Attention Virginia Residents: Any person who knowingly and w ith intent to injure,
defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any materially
false in formation o r conceals, for the purpose o f misleading, in formation concerning any fa ct material thereto commits a fraudulent act, which
is a crime an d s ubjects such pe rson to criminal and civil pena lties. Attention Washington Residents: It is a crime to knowingly provide false,
incomplete, or m isleading in formation to an insurance company for the purpose o f defrauding the company. P enalties in clude i mprisonment,
fines, and denial of insurance benefits. Attention New York Residents, the following statement applies only to your AD&D coverage:
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 a ct, which i s a crime, an d s hall be subject to a civil pen alty not to exc eed five thousand d ollars and the stated
value of the claim for each violation.
Employer Representative Name:
Employer Representative Signature:
Date (MM/DD/YYYY): Employer Phone Number and Extension:
GC-1373-14 (4-18)