Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. | page 2 | ColonialLife.com | 7-19 | 65017-17
Colonial Life & Accident Insurance Company, Columbia, SC | CRITICAL ILLNESS | Fax: 1-800-880-9325 | Telephone: 1-800-325-4368
Claim Fraud Statements
For your protection, the laws of several states, including Alaska, Arkansas, Delaware, Idaho, Indiana, Louisiana, Minnesota,
New Hampshire, Ohio, Oklahoma, and others, require the following statement to appear on this claim form. Fraud Warning: Any
person who knowingly, and with intent to injure, defraud, or deceive an insurance company, files a statement of claim containing
any false, incomplete, or misleading information is guilty of insurance fraud, which is a felony.
Alabama: Any person who knowingly presents a false or fraudulent claim
for payment of a loss or benefit or who knowingly present 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.
Arizona: For your protection Arizona law requires the following
statement to appear on this form: Any person who knowingly
presents a false or fraudulent claim for payment of a loss is
subject to criminal and civil penalties.
California, Rhode Island, Texas and West Virginia: For your protection,
California, Rhode Island, Texas and West Virginia law requires the following
to appear on this form: Any person who knowingly presents 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.
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.
Kentucky: For your protection, Kentucky law requires the following to
appear on this form: Any person who knowingly and with intent to defraud
any insurance company or other person files a 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.
Maine, Tennessee, Virginia 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 may
include imprisonment, fines or a denial of insurance benefits.
Maryland: Any person who knowingly or willfully presents
a false or fraudulent claim for payment of a loss or benefit
or who knowingly or willfully presents false information in
an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
New Jersey and New Mexico: Any person who knowingly
files a statement of claim containing any false or misleading
information 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 also be subject to a civil penalty not to exceed five
thousand dollars and the stated value of the claim for each
such violation.
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
Puerto Rico: Any person who knowingly and with the
intention of defrauding presents false information in an
insurance application, or presents, helps, or causes the
presentation of a fraudulent claim for the payment of a loss
or any other benefit, or presents more than one claim for
the same damage or loss, shall incur a felony and, upon
conviction, shall be sanctioned for each violation with the
penalty of a fine of not less than five thousand (5,000)
dollars and not more than ten thousand (10,000) dollars,
or a fixed term of imprisonment for three (3) years, or both
penalties. If aggravating circumstances are present, the
penalty thus established may be increased to a maximum
of five (5) years; if extenuating circumstances are present;
it may be reduced to a minimum of two (2) years.