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Arkansas – 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.
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 for the purpose of defrauding or
attempting to defraud the 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.
District of Columbia - 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.
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.
Hawaii – For your protection, Hawaii Law requires you to be informed that presenting a fraudulent claim for payment of a
loss or benefit is a crime punishable by fines or imprisonment, or both.
Kentucky – Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance 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.
Maine – It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
Maryland – Any person who, with intent to defraud or knowingly that his is facilitating a fraud against an insurer, submits
an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.
New Jersey – Any person who includes any false or misleading information on an application for an insurance policy 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 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/she is facilitating a fraud against any insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud, which is a crime.
Oklahoma – 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.
Oregon – Any person who, with intent to defraud or knowingly that his is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.
Pennsylvania – Any person who knowingly and with intent to injure or defraud any insurer files an application or claim
containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to 7
years and payment of a fine of up to $15,000.
Vermont
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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 may be guilty of a crime and may be subject to civil
fines and criminal penalties.
Date_ ______________________________
Applic
ant’s Signature_ __________________________________________________________________
Thi
s application does not commit the Company to any liability nor make the Applicant liable for any premium unless the
Company agrees to effect this insurance.
click to sign
signature
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