how to request excess medical benefits - Chubb Group of Insurance ...

IMPORTANT NOTICENotice to Alaska Claimants: A person whoknowingly and with intent to injure, defraud, ordeceive an insurance company files a claimcontaining false, incomplete, or misleadinginformation may be prosecuted under state law.Notice to Arizona Claimants: For your protection,Arizona law requires the following statement toappear on this form: Any person who knowinglypresents a false or fraudulent claim for payment of aloss is subject to criminal and civil penalties.Notice to Arkansas Claimants: Any person whoknowingly presents a false or fraudulent claim forpayment of a loss or benefit or knowingly presentsfalse information in an application for insurance isguilty of a crime and may be subject to fines andconfinement in prison.Notice to California Claimants: For yourprotection, California law requires the following toappear on this form: Any person who knowinglypresents a false or fraudulent claim for the paymentof a loss is guilty of a crime and may be subject tofines and confinement in state prison.Notice to Colorado Claimants: It is unlawful toknowingly provide false, incomplete, or misleadingfacts or information to an insurance company for thepurpose of defrauding or attempting to defraud thecompany. Penalties many include imprisonment,fines, denial of insurance, and civil damages. Anyinsurance company or agent of an insurancecompany who knowingly provides false, incomplete,or misleading facts or information to a policyholderor claimant for the purpose of defrauding orattempting to defraud the policyholder or claimantwith regard to a settlement or award payable frominsurance proceeds shall be reported to the ColoradoDivision of Insurance within the Department ofRegulatory Agencies.Notice to Delaware Claimants: Any person whoknowingly, and with intent to injure, defraud ordeceive any insurer, files a statement or claimcontaining any false, incomplete, or misleadinginformation is guilty of a felony.Notice to District of Columbia Claimants:WARNING: It is a crime to provide false ormisleading information to an insurer for the purposeof defrauding the insurer or any other person.Penalties include imprisonment and/or fines. Inaddition, an insurer may deny insurance benefits iffalse information materially related to a claim wasprovided by the applicant.Notice to Florida Claimants: Any person whoknowingly and with intent to injure, defraud ordeceive any insurer files a statement of claim or anapplication containing any false, incomplete, ormisleading information, is guilty of a felony of thethird degree.Notice to Idaho Claimants: Any person whoknowingly, and with intent to defraud or deceive anyinsurance company, files a statement containing anyfalse, incomplete, or misleading information, isguilty of a felony.Notice to Indiana Claimants: A person whoknowingly and with intent to defraud an insurer filesa statement of claim containing any false,incomplete, or misleading information commits afelony.Notice to Kentucky Claimants: Any person whoknowingly and with intent to defraud any insurancecompany or other person files a statement of claimcontaining any materially false information orconceals, for the purpose of misleading, informationconcerning any fact material thereto commits afraudulent insurance act, which is a crime.Notice to Maine Claimants: It is a crime toknowingly provide false, incomplete or misleadinginformation to an insurance company for thepurpose of defrauding the company. Penalties mayinclude imprisonment, fines or a denial of insurancebenefits.Notice to Maryland Claimants: Any person whoknowingly or willfully presents a false or fraudulentclaim for payment of a loss or benefit or whoknowingly or willfully presents false information inan application for insurance is guilty of a crime andmay be subject to fines and confinement in prison.