Fillable Disability Claim Form (Aflac Insurance)

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Disability Claim Form (Aflac Insurance)

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CONTINENTAL AMERICAN INSURANCE COMPANY
Post Office Box 84075 * Columbus,
GA. 31993 Phone (800) 433-3036 *
Fax (866) 849-2970
SHORT TERM DISABILITY CLAIM FORM INSTRUCTIONS
To avoid delays in processing of your claim form, complete each section attaching documentation below
when it applies.
Note: This form is for initial filing of a disability claim. If your disability is being extended, you will need to
complete the listed Supplemental Claim form.
Supporting Documentation Needed
Chart Note to include admission and discharge paperwork if there was a hospital stay
Surgical Report if surgery took place
Receipts for follow up visits or physical therapy with dates and charges if applicable
Email form to groupclaimfiling@aflac.com or fax to 1.866.849.2970.
di.agi.en.201803
CONTINENTAL AMERICAN INSURANCE COMPANY
Post Office Box 84075 * Columbus,
GA. 31993 Phone (800) 433-3036 *
Fax (866) 849-2970
SHORT TERM DISABILITY CLAIM FORM
*Please attach paperwork for any additional income you are receiving during this period of disability.*
**Please sign and return the attached Authorization.
PART A: POLICYHOLDER’S STATEMENT (FORMS ARE TO BE COMPLETED ON OR AFTER DISABILITY DATE TO AVOID PROCESSING DELAYS)
POLICY HOLDER’S NAME
POLICY/CERTIFICATE NUMBER
SOCIAL SECURITY/ ID
DATE OF BIRTH
GENDER
☐PERMANENT ADDRESS
☐ADDRESS CHANGE
POLICY HOLDER’S ADDRESS, CITY, STATE, ZIP
E-MAIL ADDRESS
* By providing your e-mail address above, you consent to the use of electronic transactions in connection with your
CAIC policies, contracts, and/or accounts to the extent available and permitted by law (which may include, but not
limited to: invoices, claim correspondence, contracts, surveys, and other materials that CAIC is, or may be, legally
required to delivery to you)
EMPLOYER NAME
OCCUPATION
IS YOUR ACCIDENT OR SICKNESS RELATED TO YOUR
OCCUPATION?
DATE REPORTED TO YOUR EMPLOYER
HAS A WORKER’S COMPENSATION CLAIM BEEN FILED? ☐ YES ☐ NO
STATUS
☐APPROVED
☐PENDING
☐DENIED IF DENIED, HAS AN APPEAL BEEN FILED? ☐ YES ☐ NO
DATE SYMPTOM FIRST APPEARED
TREATING PHYSICIAN NAME ADDRESS
IF HOSPITALIZED: (NAME/ADDRESS)
DATES HOSPITALIZED
PLEASE PROVIDE DESCRIPTION OF SICKNESS OR INJURY
DATES YOU DID NOT WORK AT ALL
FROM THROUGH
DATES YOU WORKED LESS THAN FULL TIME.
FROM THROUGH
DATE YOU RETURNED OR EXPECT TO RETURN TO WORK.
FULL-TIME PART-TIME
PRIMARY DOCTOR NAME
ADDRESS
CITY, STATE, ZIP CODE
PHONE NUMBER
TREATING DOCTOR NAME
ADDRESS
CITY, STATE, ZIP CODE
PHONE NUMBER
REFERRING DOCTOR NAME
ADDRESS
CITY, STATE, ZIP CODE
PHONE NUMBER
AUTHORIZATION
Several states require that the following statement appear on the claim forms:
For your protection, California law requires 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.
For the purpose of evaluating my eligibility for insurance and eligibility for benefits under an existing policy/certificate including checking for and resolving any issues that may arise regarding
incomplete or incorrect information on my application or claim form, I hereby authorize the disclosure of the following information about me and, if applicable, my dependents, from the sources
listed below to Continental American Insurance Company (CAIC) and its duly authorized representatives.
Disclosure of Health Information
Health information may be disclosed by any health care provider, health plan or health care clearinghouse that has any records or knowledge about me. Health care provider includes, but is not
limited to, any licensed physician, medical or nurse practitioner, nurse, pharmacist, osteopath, psychologist, physical or occupational therapist, chiropractor, dentist, audiologist or speech pathologist,
podiatrist, hospital, medical clinic or laboratory, pharmacy, rehabilitation facility, nursing home or extended care facility, prescription drug database or pharmacy benefit manager, or ambulance or other
medical transport service. Health information may also be disclosed by any insurance company or the Medical Information Bureau (MIB). Health information includes my entire medical r e cor d, but
does not include psychotherapy notes.
Financial or credit history, earnings, or employment history may be disclosed by any entity, person or organization that has these records about me, including but not limited to my employer, employer
representative and compensation sources, insurance company, financial institution or any consumer reporting agency.
Federal, state and local government organizations including but not limited to the Veteran’s Administration, Internal Revenue Service, Social Security Administration, Medicare or Medicaid
agencies, may disclose health or financial information or records about me.
Any information CAIC obtains pursuant to this authorization will be used for the purpose of evaluating and administering my claim for benefits. Some information obtained may not be protected by
certain federal regulations governing the privacy of health information, but the information is protected by state privacy laws and other applicable laws. CAIC will not disclose the information unless
permitted or required by those laws.
This authorization is valid for two (2) years from its execution or the duration of my claim, whichever is later. A copy of this authorization is as valid as the original. I know that I or my authorized
representative may request a copy of this authorization and access to this information.
This authorization may be revoked by me or my authorized representative at any time except to the extent CAIC has relied on the authorization prior to notice of revocation or has a legal right to
contest coverage under the contract or the contract itself. If I revoke this authorization, CAIC may not be able to evaluate my claim or eligibility for benefits. I may revoke this authorization by sending
written notice to: Continental American Insurance Company, Claims Department, and P.O. Box 84075, Columbus, Georgia 31993.
You may refuse to sign this form; however, CAIC may not be able to evaluate and administer your claim without this authorization.
I am the individual to whom this authorization applies or that person’s legal Guardian, Power of Attorney Designee, Conservator, Beneficiary or
personal representative.
POLICYHOLDER’S SIGNATURE: DATE:
di.agi.en.201803
Post Office Box 84075 * Columbus, GA. 31993
Phone (800) 433-3036 * Fax (866) 849-2970
groupclaimfiling@aflac.com
SHORT TERM DISABILITY CLAIM FORM
PART B: EMPLOYER’S STATEMENT:
(To be completed by your Benefits Department unless self-employed)
EMPLOYEE’S NAME
EMPLOYEE ID NUMBER
DATE OF BIRTH
DATE OF HIRE
OCCUPATION AT TIME LAST WORKED:
EMPLOYEE’S JOB TITLE DUTIES: (Please mark selection in each category)
LIFTING ☐LESS THAN 15LBS ☐ 15 TO 44 ☐OVER 45
REPETITIVE ☐NONE ☐SELDOM ☐FREQUENT
REACHING/PULLING/PUSHING ☐NONE ☐SELDOM ☐ FREQUENT
SITTING (NUMBER OF HOURS EACH DAY)
STOOPING/BENDING ☐NONE ☐SELDOM ☐ FREQUENT
CRAWLING/CLIMBING/KNEELING ☐NONE ☐SELDOM ☐ FREQUENT
MANAGEMENT DUTIES ☐NONE ☐SELDOM ☐ FREQUENT
STANDING/WALKING (HOURS EACH DAY)
DATE EMPLOYEE WAS ACTUALLY LAST PRESENT AT WORK?
WORK SCHEDULE AT TIME LAST WORKED:
DAYS/WEEK HOURS/DAY
DATES EMPLOYEE DID NOT WORK AT ALL
FROM THROUGH
DATES EMPLOYEE WORKED LESS THAN FULL-TIME HOURS
FROM THROUGH
DATE THE EMPLOYEE RETURNED TO FULL-
TIME WORK OR LIGHT
DUTY/PART-TIME
IF THE EMPLOYEE HAS NOT RETURNED, IS LIGHT DUTY AVAILABLE?
IF THE EMPLOYEE RETURNED TO WORK LIGHT DUTY/ PART TIME PLEASE PROVIDE
HOURS WORKED AND EARNINGS
DID THE CLAIM RESULT FROM JOB ACTIVITY?
HAS A WORKER'S COMPENSATION CLAIM BEEN FILED?
NO/
YES
STATUS
☐APPROVED
☐PENDING
☐DENIED
IF DENIED, HAS AN APPEAL BEEN FILED? Y/ N
HAS THE EMPLOYEE RECEIVED ANY
OTHER
INCOME AS A RESULT OF
DISABILITY?
☐NO
☐YES
SALARY CONTINUANCE, SICK PAY OR
VACATION
WEEKLY BENEFIT:
DATE CEASED
IS ANY PORTION OF THE EMPLOYEE'S
POLICY
PAID FOR
BY THE EMPLOYER?
☐NO
☐YES
IS THE EMPLOYEE’S POLICY PAID FOR
WITH
PRE-TAX DOLLARS (SECTION 125)?
☐NO
☐YES
WHAT ARE THE EMPLOYEE’S BASIC MONTHLY EARNINGS?
IF WORKING THE EMPLOYEE IS WORKING LIGHT DUTY OR PART- TIME,
PLEASE PROVIDE EARNINGS AND HOURS WORKED
AUTHORIZED EMPLOYER'S SIGNATURE
EMPLOYER’S COMPANY NAME
TELEPHONE NUMBER
FAX NUMBER
ADDRES
NAME AND TITLE OF PERSON COMPLETING THIS FORM
SIGNATURE OF AUTHORIZED EMPLOYER REPRESENTATIVE
DATE
* IF SELF-EMPLOYED, PLEASE SUBMIT 1099 FORM FOR VERIFICATION
* IF EMPLOYEE IS RECEIVING ANY OTHER INCOME, PLEASE SPECIFY TYPE AND AMOUNT OF INCOME
di.agi.en.201803
Post Office Box 84075 * Columbus, GA. 31993
Phone (800) 433-3036 * Fax (866) 849-2970
groupclaimfiling@aflac.com
SHORT TERM DISABILITY CLAIM FORM
PART C: ATTENDING PHYSICIAN’S STATEMENT (To be completed by physician certifying disability on or after disability date to avoid processing delays)
PATIENT’S NAME
DATE OF BIRTH
DATE PATIENT BECAME DISABLED DUE TO PRESENT
DIAGNOSIS
WHEN DID SYMPTOMS FIRST APPEAR OR ACCIDENT OCCUR?
HAS THE PATIENT EVER HAD SAME OR
SIMILAR CONDITION/ DIAGNOSIS?
☐YES ☐NO
IS THIS A WORKER’S COMPENSATION INJURY?
☐YES ☐NO
DATE
NAMES/ADDRESSES ANY ADDITIONAL PHYSICIANS TREATING PATIENT FOR CURRENT DIAGNOSIS
DIAGNOSIS
(INCLUDING COMPLICATIONS)
ICD CODE (S)
SUBJECTIVE SYMPTOMS
OBJECTIVE FINDINGS (INCLUDING
CURRENT X-RAYS, EKG’S, LA
BORATORY DATA AND ANY CLINICAL
FINDINGS.)
DIAGNOSIS
PREGNANCY
EDC
LMP
DATE OF
DELIVERY
METHOD OF
DELIVERY
☐VAGINAL
☐ CESAREAN
PLEASE LIST ANY PREGNANCY COMPLICATIONS
TREATMENT
DATE FIRST TREATED FOR THIS CONDITION
LAST DATE TREATED FOR THIS CONDITION
NATURE OF TREATMENT (SURGERY AND MEDICATIONS PRESCRIBED, IF ANY.)
DID PATIENT HAVE SURGERY? ☐YES ☐NO
IF YES, DATE OF SURGERY
TYPE OF
SURGERY:
HAS THE PATIENT
☐RECOVERED ☐IMPROVED ☐ UNCHANGED ☐
RETROGRESSED
IS THE PATIENT
☐
AMBULATORY ☐HOUSE CONFINED
☐ BED CONFINED ☐HOSPITAL CONFINED
IF CONFINED TO HOSPITAL, PLEASE PROVIDE DATES
CONFINED FROM: TO:
NAME AND ADDRESS OF HOSPITAL: (IF CONFINED)
WHEN DO YOU EXPECT A FUNDAMENTAL CHANGE IN THE PATIENT’S CONDITION?
(Please circle selection)
☐1 MO. ☐1-3 MO. ☐3-6 MO. ☐6-9 MO. ☐9-12MO. ☐NEVER
WHEN DO YOU ANTICIPATE A RETURN TO WORK FULL DUTY
WITHOUT RESTRICTIONS?
WHEN COULD A TRIAL EMPLOYMENT COMMENCE? (IF PATIENT RELEASED TO RETURN TO WORK WITH RESTRICTIONS) DATE (PATIENT’S JOB):
CAPACITY: ☐FULL-TIME ☐PART-TIME ☐LIGHT DUTY
PHYSICAL IMPAIRMENTS (AS DEFINED IN THE FEDERAL DICTIONARY OF OCCUPATIONAL TITLES)
CLASS 1 – NO LIMITATION OF FUNCTIONAL CAPACITY; CAPABLE OF HEAVY WORK. NO RESTRICTIONS (0-10%)
CLASS 2 – MEDIUM MANUAL ACTIVITY. (15-30%)
CLASS 3 – SLIGHT LIMITATION OF FUNCTIONAL CAPACITY; CAPABLE OF LIGHT WORK. (35-55%)
CLASS 4 – MODERATE LIMITATION OF FUNCTIONAL CAPACITY; CAPABLE OF CLERICAL/ADMINISTRATIVE (SEDENTARY) ACTIVITY. (60-70%
(75-100%)
CLASS 5 – SEVERE LIMITATION OF FUNCTIONAL CAPACITY; INCAPABLE OF MINIMUM (SEDENTARY) ACTIVITY
RESTRICTIONS AND LIMITATIONS: (What specific activities/ work duties is the patient incapable of performing)
REMARKS: (Additional comments regarding the patient’s condition)
NAME: (ATTENDING PHYSICIAN)
FAX NUMBER
TELEPHONE NUMBER
MEDICAL ID NUMBER
PHYSICIAN ADDRESS, CITY, STATE, ZIP CODE
AUTHORIZED SIGNATURE OF
PHYSICIAN
“I hereby certify that the above described information is based upon reasonable medical probability, and is true and correct to the best of my knowledge and belief.”
SIGNATURE
DATE
di.agi.en.201803
AUTHORIZATION TO OBTAIN INFORMATION
Primary Certificate Holder Name:
SSN(optional):
Date of Birth:
Certificate Number(s):
Address:
City:
State:
Zip:
Name of Individual Subject to Disclosure (If not the primary Certificate Holder):
Date of Birth:
Relationship to Primary Certificate Holder:
Self
Spouse Domestic Partner Child Stepchild Grandchild
I.
Authorization:
For the purpose of evaluating my eligibility for insurance and for benefits under an existing certificate, including checking
for and resolving any issues that may
arise regarding incomplete or incorrect information on my application for coverage
and/or claim form, I hereby authorize the disclosure of the following
information(defined below) about me and, if
applicable, my dependents, from the sources listed below to Continental American Insurance Company (CAIC), or
any
person or entity acting on its part, to include American Family Life Assurance Company of Columbus and American
Family Life Assurance Company of New
York (collectively, “Aflac).
II.
Disclosure of Health Information:
Health information may be disclosed by any health care provider, health plan (including CAIC or Aflac, with respect to other
CAIC or Aflac coverages) or health care
clearinghouse that has any records or knowledge about me. Health care provider
includes, but is not limited to, any licensed physician, medical or nurse
practitioner, nurse, pharmacist, osteopath,
psychologist, physical or occupational therapist, chiropractor, dentist, audiologist or speech pathologist, podiatrist,
hospital,
medical clinic or laboratory, pharmacy, rehabilitation facility, nursing home or extended care facility, prescription drug
database or pharmacy benefit
manager, or ambulance or other medical transport service. Health information may also be
disclosed by any insurance company or the Medical Information
Bureau (MIB). Health information includes my entire
medical record, but does not include psychotherapy notes. Some information obtained may not be protected
by certain
federal regulations governing the privacy of health information, but the information is protected by state privacy laws and
other applicable laws. CAIC
will not disclose the information unless permitted or required by those laws.
III.
Rights and Expiration:
I understand that I may revoke this authorization at any time, except to the extent that CAIC or Aflac has taken action in
reliance on this authorization. If I revoke
this authorization, CAIC may not be able to evaluate my application for coverage
and/or claim. To revoke this authorization, I must provide a written and signed
revocation to CAIC at the address or fax
number above. Unless otherwise revoked, this authorization shall remain in effect for two (2) years from the date
signed
or upon my death, whichever occurs first. I agree that a copy of this authorization is as valid as the original and that I or an
authorized representative
may request a copy of this authorization.
IV.
Notice:
I understand that CAIC is not conditioning payment, enrollment, or eligibility for benefits on whether I sign this
authorization. I understand that if the
information disclosed is protected health information relating to a health plan and the
person or entity receiving the information is a not a health care provider
or health plan covered by federal privacy
regulations, the information disclosed may be re-disclosed by such person or entity and will likely no longer be
protected
by the federal privacy regulations.
If records are on an adult dependent, (e.g. spouse, child over 18), the dependent must sign this form
If records are on a minor child the natural parent or legal guardian must sign on their behalf.
Signature of Individual Subject to Disclosure Date Signed
Legal Representative’s Printed Name Legal Representative’s Signature Legal Relationship Date
***If signed by a legal representative (e.g. Legal Guardian, Estate Administrator, Power of Attorney
Send to:
Continental American Insurance Company
Post Office Box 84075
Columbus, GA 31993
Phone: (800) 433-3036
Fax: (866) 849-2970
Email: groupclaimfiling@aflac.com
hipaa.agi.en.201803
Electronic Funds Transaction Authorization
Send to: Continental American Insurance Company Phone: (800) 433-3036 Fax (866) 849-2970
Post Office Box 84075
Email: groupclaimfiling@aflac.com
Columbus, Georgia 31993
Authorization Agreement for Direct Deposit
I would like to: Start Stop Change direct deposit of my claim payment(s).
Account Type:
Checking Savings
**** Please provide a blank voided check or
direct deposit form from your financial
institution. Incomplete or inaccurate
information will not be processed.
9-Digit Routing Number:
Account Number:
Name of Financial Institution:
Address:
City:
State:
Zip:
Phone:
I authorize Continental American Insurance Company (CAIC) to initiate credit entries, and, if errors occur, I authorize
the correction of entries to my account as indicated. This authorization remains effective and in full force until
CAIC receives written notification from me of its termination in such time and in such manner to afford CAIC a
reasonable opportunity to act on it. Please notify CAIC immediately if your financial institution information has
changed by sending notification to the address indicated above. Should you have any questions, please contact us at
1-800-433-3036.
Policy/Certificate Holder’s Name (Print):
Address:
City/State/Zip:
Phone #:
E-mail Address:
Employer Name or Group #:
Certificate #:
***By providing your e-mail address above, you consent to the use of electronic transactions in connection with your CAIC policies, contracts, and/or
accounts to the extent available and permitted by law (which may include, but not limited to: invoices, claim correspondence, contracts, surveys, and
other materials that CAIC is, or may be, legally required to deliver to you)
Note: Forms received without signature will not be processed. Electronic signatures not accepted.
Policy/Certificate Holder Signature (Required) Date Signed:
Continental American Insurance Company (CAIC), a proud member of the Aflac family of insurers, is a wholly-owned subsidiary of Aflac Incorporated and underwrites group coverage. Aflac is
not licensed to
solicit business in New York, Guam, Puerto Rico, or the Virgin Islands. For groups sitused in California, coverage is underwritten by Continental American Life Insurance
Company. For groups sitused in New
York, coverage is underwritten by American Family Life Assurance Company of New York.
Continental American Insurance Company • 1600 Williams St • Columbia, South Carolina 29201 • 1-800-433-3036 toll-free • 1-866-849-2970 fax
eft.agi.en.201803
FRAUD WARNING NOTICES
For use with Claim Forms
PLEASE READ THE FRAUD WARNING NOTICE FOR YOUR STATE
ALASKA:
A person who knowingly and with intent to
injury, defraud or deceive an insurance company files a
claim containing false, incomplete, or misleading
information may be prosecuted under state law.
IDAHO:
Any person who knowingly, and with intent to
defraud or deceive any insurance company, files a
statement of claim containing any false, incomplete, or
misleading information is guilty of a felony.
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.
INDIANA:
A person who knowingly and with intent to
defraud an insurer files a statement of claim containing
Any false, incomplete, or misleading information
commits a felony.
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.
KENTUCKY:
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.
CALIFORNIA:
For your protection California law
requires
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.
LOUISIANA:
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.
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 knowingly and willfully
presents a false or fraudulent claim for payment of a
loss
or benefit or who knowingly and willfully presents
false
information in an application for insurance is guilty
of a
crime and may be subject to fines and confinement
in
prison.
DELAWARE:
Any person who knowingly, and with intent to
injure, defraud or deceive any insurer, files a statement of
claim containing any false, incomplete or misleading
information is guilty of a felony.
MINNESOTA:
A person who files a claim with intent to
defraud or helps commit a fraud against an insurer is
guilt of a crime.
DISTRICT OF COLUMBIA: WARNING:
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.
NEW HAMPSHIRE:
Any person who, with a purpose to
injure, defraud, or deceive any insurance company, files
a
statement of claim containing any false, incomplete,
or misleading information is subject to prosecution and
punishment for insurance fraud, as provided in RSA
638:20.
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.
NEW JERSEY:
Any person who knowingly files a
statement of claim containing any false or misleading
information is subject to criminal and civil penalties.
fraudnotice.en.201804
FRAUD WARNING NOTICES (CONT.)
For use with Claim Forms
PLEASE READ THE FRAUD WARNING NOTICE FOR YOUR STATE
NEW MEXICO:
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 civil
fines and criminal
penalties.
TENNESSEE:
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.
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.
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.
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.
VIRGINIA
: 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.
OKLAHOMA: WARNING: 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.
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.
OREGON:
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 may be guilty of insurance fraud.
RHODE ISLAND and WEST VIRGINIA:
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.
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.
ALL OTHER STATES:
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 dollars ($5,000)
and not more than ten thousand dollars ($10,000), or a fixed
term of imprisonment for three (3)
years, or both penalties.
Should 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.
fraudnotice.en.201804
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Disability Claim Form (Aflac Insurance)

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