Life Insurance Form – Fill Out and Use This PDF

NEW YORK FRAUD WARNING: 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 $5000 and the stated value of the claim for each such violation.

FRAUD WARNING: Any person who, knowingly and with intent to defraud any insurance company or other person: (1) files an application for insurance or statement of claim containing any materially false information; (2) conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act. For residents of the following states, please see the last page of this form: California,

Colorado, District of Columbia, Florida, Kansas, Kentucky, Maryland, Minnesota, New Jersey, Oregon, Pennsylvania, Rhode Island, Tennessee, Texas or Virginia.

INSTRUCTIONS FOR FILING A CLAIM

THIS FORM IS FOR LIFE INSURANCE OR ACCIDENTAL DEATH PROCEEDS ONLY. COMPLETE THE FORM ACCORDING TO THE INSTRUCTIONS, TO AVOID DELAY OR RETURN OF THE FORM. IN BOXES WHICH CONTAIN THE SYMBOL i , ADDITIONAL INFORMATION IS PROVIDED WHEN HOVERING

OVER THE FIELD TO BE COMPLETED. THIS FEATURE IS ONLY AVAILABLE ON THE FILLABLE VERSION OF THIS FORM.

To The Employer/Administrator: 1. If claiming employee death benefits, please complete Sections A and C. If claiming dependent spouse or child benefits, please complete Sections A, B, and C.

2.If claiming voluntary or employee-paid benefits, please provide all of the enrollment history for the employee and the dependent (if claiming dependent benefits).

3.Please have each beneficiary review pages 1 through 10 and complete the appropriate pages.

4.Submit completed form to your assigned Claim Office with a Death Certificate, Beneficiary Designation and Enrollment Information, if applicable.

SECTION A: EMPLOYEE INFORMATION

Address (Street)

(City)

(State)

(Zip Code)

Employee’s/Member’s Marital Status

Single

Married

Widow/Widower

Separated

Divorced

Domestic Partner Relationship

Civil Union

Policy Number(s): List all policies under which benefits are due.

Occupation

i

Was insurance issued on the basis of a statement of

physical condition? (If yes, attach copy)

Yes

No

i Check all of the boxes that apply to the Employee/Member’s employment/membership status and job classification.

Hrs./Wk.

Active

Exempt

Management

Supervisory

Union Local #

Salaried

Full-time

Retired

Non-Exempt

Non-Management

Non-Supervisory

Non-Union

Hourly

Part-time

i

Basic Annual Earnings

i Effective Date of Earnings

i Employee’s Division/Location

i Policy Class #

i Amount of Insurance: If claiming voluntary benefits, please provide enrollment information.

Basic:

AD&D (Please complete only

Basic:

Life Voluntary:

Voluntary:

SIB:

if claiming AD&D benefits) :

BTA:

i Has voluntary coverage for the employee/dependent been in effect continuously since enrollment?

Yes

No

If No, please include enrollment history and enrollment forms if not already provided.

i

Date Hired/Member of

i

Effective Date of Insurance

i

Date Last Worked

Date of Death

i Premium Paid Through

i

Has an assignment been taken?

Assoc.

Date

(If yes, attach copy)

Yes

No

Was the above Considered an Employee/Association Member until his/her Date of Death?

i

Was the Employee actively at work until the date of the Dependent’s

Yes

No

If No, Please Explain

death?

Yes

No

If No, indicate reason below.

iIf the Employee was not actively at work immediately prior to his/her death or Dependent’s death, what was the reason?

Disability (STD)

Paid Leave of Absence

FMLA

Temporary Layoff

Resigned

Minnesota Continuation (Please attach COBRA form.)

Disability (LTD)

Unpaid Leave of Absence

Vacation

Sabbatical

Discharged

Other:

Was coverage still in effect through the Date of Death? If No, Please Explain

Yes

No

i Is there a Beneficiary Designation on file for this Employee/Member?

Yes

No

Please provide the most recent beneficiary designation with the claim.

Beneficiary: please review and keep for your records.

LMS-613500 Rev. 09/2017

Page 1 of 10

SECTION B: DEPENDENT SPOUSE OR DEPENDENT CHILD INFORMATION

Name of Dependent (Last Name)

(First Name)

(Middle Initial)

Date of Birth

Social Security No.

Sex

M

F

Relationship to Employee/Association Member

Amount of Dependent Insurance

Dependent’s Occupation

Life

Basic:

Voluntary:

Voluntary:

AD&D

Basic:

Was the Dependent Totally

Yes

No

If yes, Date Disability Began

Dependent’s Last Day Worked

Date of Marriage

Date of Death

Disabled?

Dependent’s Employer

Dependent’s Employer’s Telephone Number

Is Child

Full-time student

Date Last Attended School

Part-time student

SECTION C: EMPLOYER’S/ADMINISTRATOR’S CERTIFICATION

SECTION D: ACCIDENTAL DEATH INFORMATION

Email Address

Name and Address of Legal Guardian if Beneficiary is A Minor If guardianship of the minor’s estate has been established, please attach court order.

Did the Deceased convert or port his/her life insurance coverage prior to his/her death?

Yes

No

If claiming voluntary life or basic and/or voluntary AD&D benefits, please list all hospital, clinics or physicians that treated the deceased within the past 5 years.

Name

Phone Number

Complete Address

Treatment Period

I certify that the foregoing information is true, correct and complete to the best of my knowledge.

Beneficiary Signature

Date

LMS-613500 Rev. 09/2017

Page 2 of 10

Cignassurance® Program

If your insurance benefit is $5,000 or more, Cigna will automatically open a free, interest-bearing account in your name. This account, called the Cignassurance® Program, is a convenient and secure place to keep your proceeds while you decide how to best use them. Please review the attached Cignassurance® Program Disclosure Notice for full details about the account.* Account balances are the liability of the insurance company and are not insured by the Federal Deposit Insurance Corporation or any federal agency. The insurance company reserves the right to reduce account balances for any payment made in error. If your life insurance benefit is less than $5,000, Cigna will send you a check for the total benefit amount.

*Please read the Cignassurance® Program Disclosure Notice before signing below.

I understand that if my benefit is $5,000 or more, I will receive a Cignassurance® account.

I understand that I may write a draft for the total amount in my account at any time.

I understand that the account balance may be reduced for any benefit payment by the insurance company made in error.

I acknowledge that, if I do not separately sign the Cignassurance® Section of this Claim Form, I am not participating in the Cignassurance® Program and that I will receive a single lump sum check for the proceeds due if my claim is approved.

Signature*

Date

*Please sign as you would sign on a check, as signature may be used for draft verification.

The issuance of this form is not an admission of the existence of any insurance nor does it recognize the validity of any claim and is without prejudice to the company’s legal rights.

Beneficiary: Please complete and return to the Employer or Cigna.

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Page 3 of 10

ELECTRONIC COMMUNICATIONS DISCLOSURE AND CONSENT

Please read this information carefully. Then, print and keep a copy for yourself.

As a valued Cigna customer, we send you information about your benefits through the mail. This information may include:

•Claim forms, authorizations, disclosures, affidavits, electronic funds transfer agreements, privacy notices, and letters letting you know about changes to any of these items;

•Claim status updates letting you know that we’ve received a claim, or that we’ve updated the status of a claim;

•Letters asking you, or someone else, for additional information to help with the review of a claim.

Did you know that you may also give us consent to send you this information electronically?

Cigna has an easy to use tool called Secure Email that allows us to communicate with you electronically. All you need is a computer, internet access, and a personal email address (called a Designated Email).

By giving us your permission, known as consent, you understand you may no longer receive information in paper form and you accept responsibility for promptly reviewing the Secure Emails you receive. This ensures you can take appropriate action so that any benefits you are eligible for are not delayed or that any rights you have are not affected.

What do I need to know before I give my consent?

Access to Paper Copies

At any time, you can still request paper copies of information. Simply email us from your valid Designated Email, call customer service or send us a letter by mail. We keep copies of the information we email for the time periods required by law. We recommend saving or printing copies of the information you get electronically to ensure you have it when you need it.

System Requirements

To use Secure Email, access messages, and keep copies of the information we send you must have a working, personal Designated Email address and a computing or communications device with:

•16 MB of available memory (32 MB of RAM recommended) and

•a program that can view, save and print PDF files (such as Adobe® Reader® 4.0 or higher).

Our Right to Send Paper

We have the right to send you information through the mail even if you agreed to receive it electronically. For example, we may send you a letter through the mail if we have a system outage, if we suspect fraud, if for any reason your Designated Email does not accept emails from us, or if we receive notification that you have not opened your email messages in Secure Email.

Modification of Consent Terms

We reserve the right to modify (change) these terms and conditions if we choose. We will provide you with notice of a modification electronically, and the date it is to go into effect. If you do not agree to the new terms and conditions, you must notify us of your Withdrawal of Consent before the effective date. Failure to withdraw your consent, or follow the instructions in the notice, lets us know that you agree to the new terms.

Withdrawal of Consent

Your consent remains in effect until you tell us otherwise and provide a Withdrawal of Consent. You may withdraw your consent at any time if you decide you want to go back to paper information. To contact us, you may email using the same valid, personal e-mail address you used to register for Secure Email, call us at 1-800-238-2125, or send us a letter by mail. Withdrawing your consent will let us know that you want to stop receiving Secure Emails. It will not change the outcome of any information we have already sent you.

Beneficiary: Please review and keep for your records.

LMS-613500 Rev. 09/2017	Page 5 of 10

Your Consent

Please read the following paragraph, make your selection, print and sign your name, enter the date, give us your email address, and provide the employee's name and date of birth.

By signing my name below, I agree that I have read the information in this letter about Cigna's Secure Email tool and I wish to receive information electronically from Cigna. I also agree that:

1.I have technology that meets the System Requirements highlighted above,

2.I have received written instruction in this letter on how to receive and manage messages using Secure Email, and

3.I will provide and maintain a valid Designated Email and that this email belongs to me. I agree to maintain this email until I provide Cigna with a new one (if appropriate) by calling customer service or sending a letter through the mail.

4.I understand that Cigna will only send me information electronically from this point forward unless I withdraw my consent.

If Cigna does not receive your signed Consent, Cigna will continue to send paper communications. If you do not wish to receive information electronically from Cigna, do not sign or return this form to Cigna.

Select One:

I consent to receive information electronically for ALL claims for which I am eligible for benefits.

I consent to receive information electronically ONLY for the following type of claims for which I am eligible for benefits:

			Life	Accidental Death
Name:					Email Address:
			(Please print clearly)					(Please print clearly)
Signature:						Date:
Name of Employee:						Date of Birth:

Beneficiary: Please complete and return to the Employer or Cigna if you wish to participate in electronic communications.

Do not complete or return this form to the Employer or Cigna if you do not wish to participate in electronic communications.

LMS-613500 Rev. 09/2017	Page 6 of 10

How to Use Cigna Secure Email

Here’s how it works.

Cigna sends an email to a secure website where you login and retrieve it. The first time you receive a Secure Email, you need to login and register. Registration confirms your identity and is completed by following these simple instructions.

1.Open the Secure Email you receive and click on the enclosed link. This opens the registration page.

2.Enter your first, middle (optional) and last name in the space provided.

3.Enter a password and password reminder that you choose.

4.Select two security questions from the drop down menu and provide answers you can easily remember.

5.Click the register button. An email confirmation is sent to your personal email address we have on file.

6.Now, check your personal email inbox. Open the email titled Secure Email Registration Confirmation and click the link. Your account is now active!

After you have successfully registered for Secure Email, you are ready to read, reply, forward and create messages.

•To Read Messages in your Inbox: The Inbox page lists messages that you received within the last 60 days. You can read, reply, forward, download and delete messages in your Inbox. In addition, you may print any message and download attachments.

•To Create a Message: The Compose option is available so that you may reach out and contact Cigna. Please note that this feature is restricted to sending messages to Cigna employees only.

What if I forget my password?

If you forget your password, you may request a reminder from the login page (https://www.cignasecure.com). You need to know the personal email address you used when you registered for Secure Email.

Where can I get help?

The Cigna Customer Support Center provides support for the Secure Email tool. You can reach them at 800-284-8346 or at 856-346-5301.

Beneficiary: Please review and keep for your records.

LMS-613500 Rev. 09/2017

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Cignassurance® Program Disclosure Notice

Cignassurance® Program Disclosure

If your insurance benefit is $5,000 or more, Cigna will establish a free, interest-bearing draft account in your name. This account is a convenient and secure place to keep your proceeds while you decide how to best use them. A supply of personalized drafts (checks) will be mailed to you, once your claim has been approved. Personalized drafts are provided free of charge, and there are no per-draft fees, maintenance charges or penalties for withdrawal. There are charges for the following special services: drafts returned unpaid ($10), stop payment ($12) and copy of draft or statement ($2).

You will receive a quarterly statement for your Cignassurance® account, which will detail your account balance, interest earned, drafts cleared, and current interest rate. You may also check your account balance online at any time at www.cignassurance.com.

Drafts are cleared through a draft account at BNY Mellon Bank (contact information on next page). Cigna’s obligation to pay is satisfied by depositing the total proceeds in the retained asset account. Drafts draw upon funds held by Cigna (whereas a "check" draws upon funds held by a banking institution). You may write an unlimited number of drafts, in any amount, at any time up to your account balance. If you wish to withdraw the proceeds in full, you can write a draft for the total amount of the account at any time. You also have the right to receive an initial lump-sum payment in the form of a bank check. Please note that Cigna reserves the right to reduce account balances for any payment made in error. You also have the right to name a beneficiary to your account. If an account becomes inactive (as defined by your State’s Department of Insurance), Cigna will return any remaining balance held in a RAA to your State of residence if no named beneficiary can be located.

This account is not insured by the Federal Deposit Insurance Corporation or any federal agency, but is guaranteed by the state guarantee association. Please contact the National Organization of Life and Health Insurance website (www.nolhga.com) to learn more about the coverage limitations to the account under a state guaranty association.

All funds are held by the insurance company, or one of its affiliates, which, like a bank, may earn money on the invested amounts that exceed the interest credited to the account and the cost of the additional benefits and services described below. For beneficiaries under policies issued by Connecticut General Life Insurance Company (CGLIC) and Life Insurance Company of North America (LINA), the custodian of the account funds will be CGLIC. For beneficiaries under policies issued by Cigna Life Insurance Company of New York (CLICNY), the custodian of the accounts funds will be CLICNY.

Disclosure on Interest Earned

You earn an attractive interest rate on the funds in your Cignassurance® Program Account from the day it is established until the date it is closed. The Cignassurance® Program interest rate is reviewed weekly and will be based upon the previous week’s Bank Rate Monitor Index (BRM) or any successor money market index. The BRM Index is the average annual effective yield earned on the money market accounts offered by 100 large US Bank and Thrifts across the country. Any amount that remains in the account will continue to earn interest at a rate equal to the national average bank money market rate.

Please call our toll-free number 855.836.0697 for the current rate. Both your principal and any interest you earn are guaranteed by the insurance company. Any interest earned on the account may be taxable and you should consult a tax, investment, or other financial advisor regarding tax liability and investment options. Interest earned on your account is compounded daily and is credited to your account on the fifth day of each month. All funds, including earned interest, are fully guaranteed by the insurance company.

If you have additional questions or would like additional information about the Cignassurance® Program, you can call us at 800.570.3778

Or write us at: Cignassurance® Program PO Box 534029 Pittsburgh, PA 15253-4029

For further information, please contact your State Department of Insurance using the information provided on the next page.

Draft Accounts are setup by BNY Mellon Bank, located at 500 Ross Street, Pittsburgh, PA 15262.

The issuance of this notice is not the admission of the existence of any insurance nor does it recognize the validity of any claim and is without

prejudice to the company’s legal rights with respect to the insurance.

Beneficiary: Please review and keep for your records.

LMS-613500 Rev. 09/2017	Page 8 of 10

Cignassurance® Program Disclosure Notice

State Insurance Department Contact Information

Alabama	Alaska	Arizona	Arkansas	California
PO Box 303351	PO Box 110805	2910 N. 44th Street, STE 210	1200 West Third Street	300 South Spring Street,
Montgomery, AL 36130	Juneau, AK 99811	Phoenix, AZ 85018	Little Rock, AR 72201	South Tower
(334) 269-3550	(800) 467-8725	(602) 364-3100	(800) 282-9134	Los Angeles, CA 90013
www.aldoi.gov	www.commerce.alaska.gov/ins	www.id.state.az.us	www.insurance.arkansas.gov	(800) 927-4357
				www.insurance.ca.gov

Colorado	Connecticut	Delaware	Florida	Georgia
1560 Broadway, STE 850	153 Market Street	841 Silver Lake Blvd.	200 East Gaines Street	2 Martin Luther King, Jr. Dr
Denver, CO 80202	Hartford, CT 06103	Dover, DE 19904	Tallahassee, FL 32399	West Tower, STE 704
(800) 930-3745	(800) 203-3447	(800) 282-8611	(850) 413-3140	Atlanta, GA 30334
www.dora.state.co.us/insurance	www.ct.gov/cid	www.delawareinsurance.gov	www.floir.com	(800) 656-2298
				www.gainsurance.org

Hawaii	Idaho	Illinois	Indiana	Iowa
PO Box 3614	700 West State Street	320 W Washington	311 W Washington Street,	330 Maple St.
Honolulu, HI 96811	PO Box 83720	Springfield, IL 62767	STE 300	Des Moines, IA 50319
(808) 586-2790	Boise, ID 83720	(866) 445-5364	Indianapolis, IN 46204	(877) 955-1212
www.hawaii.gov/dcca/ins	(208) 334-4250	www.insurance.illinois.gov	(317) 232-2385	www.iid.state.ia.us
	www.doi.idaho.gov		http://www.in.gov/idoi

Kansas	Kentucky	Louisiana	Maine	Maryland
420 SW 9th Street	PO Box 517	1702 N. Third Street	34 State House Station	200 St. Paul Place, STE 2700
Topeka, KS 66612	Frankfort, KY 40602	PO Box 94214	Augusta, ME 04333	Baltimore, MD 21202
(800) 432-2484	(800) 595-6053	Baton Rouge, LA 70802	(800) 300-5000	(800) 492-6116
www.ksinsurance.org	www.insurance.ky.gov	(800) 259-5300	www.maine.gov/pfr/insurance	www.mdinsurance.state.md.us
		www.ldi.louisiana.gov

Massachusetts	Michigan	Minnesota	Mississippi	Missouri
1000 Washington Street,	PO Box 30220	85 7th Place East, STE 500	PO Box 79	PO Box 690
STE 810	Lansing, MI 48909	Saint Paul, MN 55101	Jackson, MS 39205	Jefferson City, MO 65102
Boston, MA 02118	(877) 999-6442	(651) 296-4026	(800) 562-2957	(573) 751-4126
(617) 521-7794	www.michigan.gov/ofir	www.insurance.mn.gov	www.mid.state.ms.us	www.insurance.mo.gov
www.mass.gov/doi

Montana	Nebraska	Nevada	New Hampshire	New Jersey
840 Helena Ave.	PO Box 82089	1818 E. College Pkwy.,	21 South Fruit Street, STE 14	20 West State Street
Helena, MT 59601	Lincoln, NE 68501	STE 103	Concord, NH 03301	PO Box 325
(406) 444-2040	(877) 564-7323	Carson City, NV 89706	(800) 852-3416	Trenton, NJ 08625
www.sao.mt.gov	www.doi.ne.gov	(888) 872-3234	www.nh.gov/insurance	(800) 446-7467
		www.doi.nv.gov		www.state.nj.us/dobi

New Mexico	New York	North Carolina	North Dakota	Ohio
1120 Paseo De Peralta	One State Street	1201 Mail Service Center	600 E. Boulevard Ave.	50 W. Town Street, STE 300
PO Box 1269	New York, NY 10004	Raleigh, NC 27699	Bismarck, ND 58505	Columbus, OH 43215
Santa Fe, NM 87501	(800) 342-3736	(800) 546-5664	(800) 247-0560	(800) 686-1526
(888) 427-5772	www.dfs.ny.gov	www.ncdoi.com	www.nd.gov/ndins	www.insurance.ohio.gov
www.nmprc.state.nm.us/id.htm

Oklahoma	Oregon	Pennsylvania	Rhode Island	South Carolina
3625 NW 56th, STE 100	PO Box 14480	1326 Strawberry Square	1511 Pontiac Avenue	PO Box 100105
Oklahoma City, OK 73112	Salem, OR 97309	Harrisburg, PA 17120	Cranston, RI 02920	Columbia, SC 29202
(800) 522-0071	(888) 877-4894	(877) 881-6388	(401) 462-9500	(803) 737-6160
www.ok.gov/oid	www.cbs.state.or.us/ins/index.html	www.ins.state.pa.us	http://www.dbr.state.ri.us	www.doi.sc.gov

South Dakota	Tennessee	Texas	Utah	Vermont
445 East Capitol Avenue	500 James Robertson Pkwy.	PO Box 149104	450 N State Street, STE 3110	89 Main Street
Pierre, SD 57501	Nashville, TN 37243	Austin, TX 78714	Salt Lake City, UT 84114	Montpelier, VT 05620
(605) 773-3563	(615) 741-2176	(800) 252-3439	(800) 439-3805	(802) 828-3301
www.dlr.sd.gov/insurance/default.	www.tn.gov/commerce/insurance	www.tdi.texas.gov	www.insurance.utah.gov	www.dfr.vermont.gov
aspx

Virginia	Washington	West Virginia	Wisconsin	Wyoming
PO Box 1157	PO Box 40256	PO Box 50540	PO Box 7873	106 East 6th Avenue
Richmond, VA 23218	Olympia, WA 98504	Charleston, WV 25305	Madison, WI 53707	Cheyenne, WY 82002
(800) 552-7945	(800) 562-6900	(888) 879-9842	(800) 236-8517	(800) 438-5768
www.scc.virginia.gov/boi	www.insurance.wa.gov	www.wvinsurance.gov	www.oci.wi.gov	www.insurancestate.wy.us

The issuance of this notice is not the admission of the existence of any insurance nor does it recognize the validity of any claim and is without

prejudice to the company’s legal rights with respect to the insurance.

Beneficiary: Please review and keep for your records.

LMS-613500 Rev. 09/2017	Page 9 of 10

IMPORTANT CLAIM NOTICE

California Residents: 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.

Colorado Residents: 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 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 Residents: 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.

Florida Residents: 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.

Kansas Residents: Any person who knowingly and with intent to defraud any insurance company or other person

(1)files an application for insurance or statement of claim containing any materially false information; or (2) conceals for the purpose of misleading, information concerning any material fact thereto, may be guilty of insurance fraud determined by a court of law.

Kentucky Residents: 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.

Maryland Residents: 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.

Minnesota Residents: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

Oregon Residents: Any person who knowingly and with intent to defraud any insurance company or other

person: (1) files an application for insurance or statement of claim containing any materially false information; or,

(2)conceals for the purpose of misleading, information concerning any material fact, may have committed a fraudulent insurance act.

Pennsylvania Residents: 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.

Rhode Island Residents: 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.

Tennessee Residents: 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.

Texas Residents: 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.

Virginia Residents: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits application or files a claim containing a false or deceptive statement may have violated state law.