Applicable in 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.
Applicable in 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 payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison
Applicable in Nevada Pursuant to NRS 686A.291, any person who knowingly and willfully files a statement of claim that contains any false, incomplete or misleading information concerning a material fact is guilty of a felony.
Applicable in Washington State 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.
PUBLIC ENTITY CONTACT INFO
3855 Johns Creek Parkway Suwanee, GA 30024
TOL 770.622.1600 FAX 770.622.1690
Hours of Operation Mon.-Fri. 8:00 AM - 5:00 PM EST