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The
Guardian
LifeInsurance
Com
panyofA
merica,N
ewY
ork,NY
10004
Group
Num
ber:00475402
DELT
AA
DM
INIST
RA
TIV
ESER
VIC
ESLLC
Here
you'llfindinform
ationaboutyour
following
employee
benefit(s).Be
sureto
reviewthe
enclosed-itprovides
everythingyou
needto
signup
foryour
Guardian
benefits.
PLA
NH
IGH
LIGH
TS
•D
ental•
Vision
key* 00475402 0001 E V14.0
THISPAGE
INTENTIONALLYLEFT
BLANK
2
Benefitinform
ationillustrated
within
thism
aterialreflectsthe
plancovered
byG
uardianas
of05/17/2017
Group
Num
ber:00475402
About
Your
Benefits:
Avisit
toyour
dentistcan
helpyou
keepa
greatsm
ileand
preventm
anyhealth
issues.Butdentalcare
canbe
costlyand
youcan
befaced
with
unforeseenexpenses.
Did
youknow
,acrow
ncan
costas
much
as$1,400
1?G
uardiandentalinsurance
willhelp
youpay
forit.W
ithaccess
toone
ofthelargest
network
ofdentalprovidersin
thecountry,w
hoagreed
tocharge
negotiatedfees
fortheir
servicesofup
to30%
lessthan
averagecharges
inthe
same
comm
unity,you
willbenefit
fromlow
erout-of-pocket
costs,qualitycare
fromscreened
andreview
eddentist,no
claimform
sto
file,andexcellent
customer
service.Enrolltoday
andsm
ilenext
time
yousee
yourdentist!
1http://health.costhelper.com/dental-crow
n.html.
With
yourP
PO
plan,youcan
visitany
dentist;butyou
payless
out-of-pocketw
henyou
choosea
PPOdentist.
DELTA
AD
MIN
ISTRATIVE
SERVICES
LLCBenefit
Summ
aryThe
Guardian
LifeInsurance
Com
panyofA
merica,7
Hanover
Square,New
York,NY
10004
DentalB
enefitSum
mary
DE
LTA
AD
MIN
ISTR
AT
IVE
SER
VIC
ES
LLC
Your
DentalP
lanP
PO
Your
Netw
orkis
DentalG
uardPreferred
Calendar
yeardeductible
In-Netw
orkO
ut-of-Netw
orkIndividual
$50$50
Family
limit
3per
family
Waived
forPreventive
PreventiveC
hargescovered
foryou
(co-insurance)In-N
etwork
Out-of-N
etwork
PreventiveC
are100%
100%Basic
Care
100%80%
Major
Care
60%50%
Orthodontia
50%50%
AnnualM
aximum
Benefit
$1000M
aximum
Rollover
Yes
Rollover
Threshold
$500R
olloverA
mount
$250R
olloverIn-netw
orkA
mount
$350R
olloverA
ccountLim
it$1000
Lifetime
Orthodontia
Maxim
um$1000
Dependent
Age
Limits
26
3
ASam
pleofServices
Covered
byY
ourP
lan:
DELTA
AD
MIN
ISTRATIVE
SERVICES
LLCBenefit
Summ
aryThe
Guardian
LifeInsurance
Com
panyofA
merica,7
Hanover
Square,New
York,NY
10004
PP
OPlan
pays(on
average)In-netw
orkO
ut-of-network
PreventiveC
areC
leaning(prophylaxis)
100%100%
Frequency:O
nceEvery
6M
onthsFluoride
Treatm
ents100%
100%Lim
its:U
nderAge
14O
ralExams
100%100%
Sealants(per
tooth)100%
100%X
-rays100%
100%
BasicC
areFillings ‡
100%80%
Simple
Extractions100%
80%
Major
Care
Anesthesia*
60%50%
Bridgesand
Dentures
60%50%
Inlays,Onlays,V
eneers**60%
50%Perio
Surgery60%
50%PeriodontalM
aintenance60%
50%Frequency:
Once
Every6
Months
(Standard)R
epair&
Maintenance
ofC
rowns,Bridges
&D
entures60%
50%
Root
Canal
60%50%
Scaling&
RootPlaning(per
quadrant)60%
50%Single
Crow
ns60%
50%SurgicalExtractions
60%50%
Orthodontia
Orthodontia
50%50%
Limits:
Adults
&C
hild(ren)T
hisis
onlya
partiallistofdentalservices.Y
ourcertificate
ofbenefitsw
illshowexactly
what
iscovered
andexcluded.**For
PPOand
orIndem
nitym
embers,C
rowns,Inlays,O
nlaysand
LabialVeneers
arecovered
onlyw
henneeded
becauseofdecay
orinjury
orother
pathologyw
henthe
toothcannot
berestored
with
amalgam
orcom
positefiling
material.W
henO
rthodontiacoverage
isfor
"Child(ren)"
only,theorthodontic
appliancem
ustbe
placedprior
tothe
agelim
itset
byyour
plan;Iffull-time
statusis
requiredby
yourplan
inorder
torem
aininsured
aftera
certainage;then
orthodonticm
aintenancem
aycontinue
aslong
asfull-tim
estudent
statusis
maintained.IfO
rthodontiacoverage
isfor
"Adults
andC
hild(ren)"this
limitation
doesnot
apply.The
totalnumber
ofcleaningsand
periodontalmaintenance
proceduresare
combined
ina
12m
onthperiod.*G
eneralAnesthesia
–restrictions
apply.‡For
PPOand
orIndem
nitym
embers,Fillings
–restrictions
may
applyto
composite
fillings.This
handoutisfor
illustrativepurposes
onlyand
isan
approximation.Ifany
discrepanciesbetw
eenthis
handoutandyour
paycheckstub
exist,your
paycheckstub
prevails.
Manage
Your
Benefits:
Go
tow
ww
.GuardianA
nytime.com
toaccess
secureinform
ationabout
yourG
uardianbenefits
includingaccess
toan
image
ofyourID
Card.Your
on-lineaccount
willbe
setup
within
30days
afteryour
planeffective
date..
FindA
Dentist:
Visitw
ww
.GuardianA
nytime.com
Click
on“Find
AProvider”;You
willneed
toknow
yourplan,
which
canbe
foundon
thefirst
pageofyour
dentalbenefitsum
mary.
EX
CLU
SION
SA
ND
LIMIT
AT
ION
Sn
ImportantInform
ationaboutG
uardian’sD
entalGuard
Indemnity
andD
entalGuard
PreferredN
etwork
PPOplans:T
hispolicy
providesdental
insuranceonly.C
overageis
limited
tothose
chargesthat
arenecessary
toprevent,diagnose
ortreat
dentaldisease,defect,orinjury.D
eductiblesapply.
Theplan
doesnotpay
for:oralhygieneservices
(exceptas
coveredunder
preventiveservices),orthodontia
(unlessexpressly
providedfor),cosm
eticor
experimentaltreatm
ents(unless
theyare
expresslyprovided
for),anytreatm
entsto
theextentbenefits
arepayable
byany
otherpayor
orfor
which
nocharge
ism
ade,prostheticdevices
unlesscertain
conditionsare
met,and
servicesancillary
tosurgicaltreatm
ent.The
planlim
itsbenefits
fordiagnostic
consultationsand
forpreventive,restorative,endodontic,periodontic,and
prosthodonticservices.The
services,exclusionsand
limitations
listedabove
donotconstitute
acontractand
area
summ
aryonly.T
heG
uardianplan
documents
arethe
finalarbiterofcoverage.C
ontract#G
P-1-DG
2000etal.
nP
PO
andor
Indemnity
SpecialLimitation:Teeth
lostormissing
beforea
coveredperson
becomes
insuredby
thisplan.A
coveredperson
may
haveone
orm
orecongenitally
missing
teethorhave
lostoneor
more
teethbefore
hebecam
einsured
bythisplan.
We
won’tpay
foraprosthetic
devicew
hichreplaces
suchteeth
unlessthe
devicealso
replacesoneor
more
naturalteethlostorextracted
afterthecovered
personbecam
einsured
bythisplan.R3-D
G2000
4
About
Your
Benefits:
Eyecare
isa
vitalcomponent
ofahealthy
lifestyle.With
visioninsurance,having
regularexam
sand
purchasingcontacts
orglasses
issim
pleand
affordable.Thecoverage
isinexpensive,yet
thebenefits
canbe
significant!Guardian
providesrich,flexible
plansthat
allowyou
tosafeguard
yourhealth
while
savingyou
money.Review
yourplan
optionsand
seew
hyvision
insurancem
aybe
agreat
benefitfor
you.
Vision
Benefit
Summ
ary
Visitany
doctorw
ithyour
FullFeatureplan,but
saveby
visitingany
ofthe50,000+
locationsin
thenation's
largestvision
network.
Group
Num
ber:00475402
DELTA
AD
MIN
ISTRATIVE
SERVICES
LLCBenefit
Summ
aryThe
Guardian
LifeInsurance
Com
panyofA
merica,7
Hanover
Square,New
York,NY
10004
DE
LTA
AD
MIN
ISTR
AT
IVE
SER
VIC
ES
LLC
Benefitinform
ationillustrated
within
thism
aterialreflectsthe
plancovered
byG
uardianas
of05/17/2017
Your
Vision
Plan
FullFeature
Your
Netw
orkis
VSP
Netw
orkSignature
Plan
Copay
Exams
Copay
$10
Materials
Copay
(waived
forelective
contactlenses)$
25
Sample
ofCovered
ServicesYou
pay(after
copayifapplicable):
In-network
Out-of-netw
ork
EyeExam
s$0
Am
ountover
$46
SingleV
isionLenses
$0A
mount
over$47
LinedBifocalLenses
$0A
mount
over$66
LinedT
rifocalLenses$0
Am
ountover
$85
LenticularLenses
$0A
mount
over$125
Frames
80%ofam
ountover
$120¹A
mount
over$47
Contact
Lenses(Elective)
Am
ountover
$120A
mount
over$120
Contact
Lenses(M
edicallyN
ecessary)$0
Am
ountover
$210
Contact
Lenses(Evaluation
andfitting)
15%offU
CR
No
discounts
Cosm
eticExtras
Avg.30%
offretailpriceN
odiscounts
Glasses
(Additionalpairoffram
esand
lenses)20%
offretailprice^N
odiscounts
LaserC
orrectionSurgery
Discount
Up
to15%
offtheusualcharge
or5%
offpromotionalprice
No
discounts
ServiceFrequencies
Exams
Every12
months
Lenses(for
glassesor
contactlenses)‡‡Every
12m
onths
Frames
Every24
months
Netw
orkdiscounts
(cosmetic
extras,glassesand
contactlensprofessionalservice)
Limitless
within
12m
onthsofexam
.
Dependent
Age
Limits
26Visit
ww
w.G
uardianAnytim
e.comand
clickon
“Finda
Provider”
VSP•
‡‡Benefitincludes
coveragefor
glassesor
contactlenses,notboth.
•^
Forthe
discounttoapply
yourpurchase
mustbe
made
within
12m
onthsofthe
eyeexam
.Inaddition
Full-Featureplans
offer30%
offadditionalprescriptionglasses
andnonprescription
sunglasses,includinglens
options,ifpurchasedon
thesam
eday
asthe
eyeexam
fromthe
same
VSP
doctorw
hoprovided
theexam
.
5
DELTA
AD
MIN
ISTRATIVE
SERVICES
LLCBenefit
Summ
aryThe
Guardian
LifeInsurance
Com
panyofA
merica,7
Hanover
Square,New
York,NY
10004
•C
hargesfor
aninitialpurchase
canbe
usedtow
ardthe
materialallow
ance.Any
unusedbalance
remaining
afterthe
initialpurchasecannot
bebanked
forfuture
use.Theonly
exceptionw
ouldbe
ifam
ember
purchasescontact
lensesfrom
anout
ofnetwork
provider,mem
berscan
usethe
balancetow
ardsadditionalcontactlenses
within
thesam
ebenefitperiod.
•1Extra
$20on
selectbrands
Thishandout
isfor
illustrativepurposes
onlyand
isan
approximation.Ifany
discrepanciesbetw
eenthis
handoutand
yourpaycheck
stubexist,your
paycheckstub
prevails.
Manage
Your
Benefits:
Go
tow
ww
.GuardianA
nytime.com
toaccess
secureinform
ationabout
yourG
uardianbenefits
includingaccess
toan
image
ofyourID
Card.Your
on-lineaccount
willbe
setup
within
30days
afteryour
planeffective
date.
EX
CLU
SION
SA
ND
LIMIT
AT
ION
SIm
portantInformation:This
policyprovides
visioncare
limited
benefitshealth
insuranceonly.
Itdoesnotprovide
basichospital,basic
medicalor
major
medicalinsurance
asdefined
bythe
New
YorkState
InsuranceD
epartment.
Coverage
islim
itedto
thosecharges
thatare
necessaryfor
aroutine
visionexam
ination.Co-pays
apply.The
plandoes
notpayfor:orthoptics
orvision
trainingand
anyassociated
supplementaltesting;m
edicalorsurgicaltreatm
entofthe
eye;andeye
examination
orcorrective
eyewear
requiredby
anem
ployeras
acondition
ofemploym
ent;replacement
oflensesand
frames
thatarefurnished
underthis
plan,which
arelostor
broken(exceptatnorm
alintervals
when
servicesare
otherwise
availableor
aw
arrantyexists).T
heplan
limits
benefitsfor
blendedlenses,oversized
lenses,photochromic
lenses,tinted
lenses,progressivem
ultifocallenses,coatedor
laminated
lenses,afram
ethatexceeds
planallow
ance,cosmetic
lenses;U-V
protectedlenses
andoptionalcosm
eticprocesses.
The
services,exclusions
andlim
itationslisted
abovedo
notconstitute
acontract
andare
asum
mary
only.The
Guardian
plandocum
entsare
thefinal
arbiterofcoverage.C
ontract#GP-1-VSN
-96-VIS
etal.
LaserC
orrectionSurgery:
On
average,15%offthe
usualchargeor
5%offprom
otionalpricefor
visionlaser
surgery.Mem
bers’out-of-pocketcostsare
limited
to$1,800
pereye
forLA
SIKand
$1,500per
eyefor
PRK.
Lasersurgery
isnotan
insuredbenefit.
Thesurgery
isavailable
atadiscounted
fee.The
coveredperson
mustpay
theentire
discountedfee.In
addition,thelaser
surgerydiscount
may
notbeavailable
inallstates.
6
1w
ww
.guardian
life.com
DE
TAC
HE
NTIR
EFO
RM
AN
DR
ETU
RN
TOY
OU
RE
MP
LOY
ER
DATE
FOR
MPU
BLISHED
:M
ay18,2017
TheGuardian
LifeInsurance
Company
ofAmerica
Enrollment/Change
FormPage
1of4
GuardianLife,P.O.Box
14319,Lexington,KY
40512Please
printclearlyand
mark
carefully.
Andits
Affiliatesand
Subsidiaries
CE
F2015-R-LA
EmployerNam
e:DELTA
ADM
INISTR
ATIVESER
VICESLLC
GroupPlan
Number:00475402
BenefitsEffective:_____________
PLEASECHECK
APPROPRIATEBOX
qInitialEnrollm
entq
Re-Enrollment
qAdd
Employee/Dependents
qDrop/Refuse
Coverageq
Information
Change
qIncrease
Amount
qFam
ilyStatus
Change
Class:___________________Division:_________________
SubtotalCode:____________________(Please
obtainthis
fromyourEm
ployer)
AboutYou:SocialSecurity
Number
First,MI,LastNam
e:___
______
-______
-______
______
AddressCity
StateZip
Gender:qM
qF
DateofBirth
(mm
-dd-yy):____-____
-____Phone:(
)-
EmailAddress:
Areyou
married
ordoyou
havea
spouse?q
Yes qNo
Dateofm
arriage/union:____-____-_____Do
youhave
childrenorotherdependents?
qYes q
NoPlacem
entdateofadopted
child:____-____-_____
AboutYourJob:Hours
worked
perweek:_______
JobTitle:
Work
Status:
qActive
qRetired
qCobra/State
ContinuationDate
offulltime
hire:____-____
-____
AboutYourFamily:
Pleaseinclude
thenam
esofthe
dependentsyou
wish
toenrollforcoverage.A
dependentisa
personthatyou,
asa
taxpayer,claim;w
horelies
onyou
forfinancialsupport;andforw
homyou
qualifyfora
dependencytax
exception.Dependency
taxexem
ptionsare
subjecttoIR
Srules
andregulations.Additionalinform
ationm
aybe
requiredfornon-standard
dependentssuch
asa
grandchild,aniece
oranephew
.Spouse
(First,MI,LastNam
e)
Address/City/State/Zip:
Phone:()
-
Gender
qM
qF
SocialSecurityNum
ber
_____-_____
-_____
DateofBirth
(mm
-dd-yyyy)
____-____
-____
Child/Dependent1:
Address/City/State/Zip:
Phone:()
-
qAdd
qDrop
Gender
qM
qF
SocialSecurityNum
ber
_____-_____
-_____
DateofBirth
(mm
-dd-yyyy)
____-____
-____
Status(check
allthatapply)q
Student(posthighschool)
qDisabled
qNon
standarddependent
Child/Dependent2:
Address/City/State/Zip:
Phone:()
-
qAdd
qDrop
Gender
qM
qF
SocialSecurityNum
ber
_____-_____
-_____
DateofBirth
(mm
-dd-yyyy)
____-____
-____
Status(check
allthatapply)q
Student(posthighschool)
qDisabled
qNon
standarddependent
2
DE
TAC
HE
NTIR
EFO
RM
AN
DR
ETU
RN
TOY
OU
RE
MP
LOY
ER
Child/Dependent3:
Address/City/State/Zip:
Phone:()
-
qAdd
qDrop
Gender
qM
qF
SocialSecurityNum
ber
_____-_____
-_____
DateofBirth
(mm
-dd-yyyy)
____-____
-____
Status(check
allthatapply)q
Student(posthighschool)
qDisabled
qNon
standarddependent
Child/Dependent4:
Address/City/State/Zip:
Phone:()
-
qAdd
qDrop
Gender
qM
qF
SocialSecurityNum
ber
_____-_____
-_____
DateofBirth
(mm
-dd-yyyy)
____-____
-____
Status(check
allthatapply)q
Student(posthighschool)
qDisabled
qNon
standarddependent
Drop
Coverage:q
DropEm
ployeeq
DropDependents
Thedate
ofwithdraw
alcannotbepriorto
thedate
thisform
iscom
pletedand
signed.LastDay
ofCoverage:_____-_____-_____q
Termination
ofEmploym
entq
Retirement
LastDayW
orked:_____-_____-_____q
OtherEvent:_____________Date
ofEvent:_____-_____-_____
CoverageBeing
Dropped:
qDental
qEm
ployeeq
Spouseq
Child(ren)q
Visionq
Employee
qSpouse
qChild(ren)
LossO
fOtherCoverage:
Iand/ormy
dependentsw
erepreviously
coveredunderanotherinsurance
plan.Lossofcoverage
was
dueto:
qTerm
inationofEm
ployment:
_____-_____-_____q
Divorce_____-_____-_____
qDeath
ofSpouse_____-_____-_____
qTerm
ination/ExpirationofCoverage
_____-_____-_____Coverage
Lostq
Dentalq
Vision
Ihavebeen
offeredthe
abovecoverage(s)and
wish
todrop
enrollmentforthe
following
reasons:q
Coveredunderanotherinsurance
planq
Other____________________________________________________(additionalinform
ationm
aybe
required)
DentalCoverage:
Youm
ustbeenrolled
tocoveryourdependents.
Checkonly
onebox.
Employee
OnlyEE
&Spouse
EE&
Dependent/Child(ren)EE,Spouse
&Dependent/Child(ren)
PPOq
q
qIdo
notwantthis
coverage.Ifyoudo
notwantthis
DentalCoverage,pleasem
arkallthatapply:
qIam
coveredunderanotherDentalplan
qM
yspouse
iscovered
underanotherDentalplanq
My
dependentsare
coveredunderanotherDentalplan
VisionCoverage:
Youm
ustbeenrolled
tocoveryourdependents.
Checkonly
onebox.
Employee
OnlyEE
&Spouse
EE&
Dependent/Child(ren)EE,Spouse
&Dependent/Child(ren)
FullFeatureq
q
qIdo
notwantthis
coverage.Ifyoudo
notwantthis
VisionCoverage,please
mark
allthatapply:
qIam
coveredunderanotherVision
plan
qM
yspouse
iscovered
underanotherVisionplan
qM
ydependents
arecovered
underanotherVisionplan
GuardianGroup
PlanNum
ber:00475402Please
printemployee
name:
DE
TAC
HE
NTIR
EFO
RM
AN
DR
ETU
RN
TOY
OU
RE
MP
LOY
ER
ww
w.gu
ardianlife.com
3
Signature
lAn
employee's
decisionto
electVisionornotelectVision
mustbe
retaineduntilthe
nextplan'sOpen
Enrollmentperiod.Ifthe
employee
electsnotto
enrollinvision
coverage,theyare
noteligibleto
enrolluntiltheplan's
nextOpenEnrollm
entperiod.
lIunderstand
thatmy
dependent(s)cannotbeenrolled
foracoverage
ifIamnotenrolled
forthatcoverage.
lSubm
issionofthis
formdoes
notguaranteecoverage.Am
ongotherthings,coverage
iscontingentupon
underwriting
approvalandm
eetingthe
applicableeligibility
requirements
assetforth
inthe
applicablebenefitbooklet.
lIfcoverage
isw
aivedand
youlaterdecide
toenroll,late
entrantpenaltiesm
ayapply.You
may
alsohave
toprovide,atyourow
nexpense,proofofeach
person'sinsurability.Guardian
oritsdesignee
hasthe
righttorejectyourrequest.
lPlan
designlim
itationsand
exclusionsm
ayapply.Forcom
pletedetails
ofcoverage,pleasereferto
yourbenefitbooklet.Statelim
itationsm
ayapply.
lIhereby
applyforthe
groupbenefit(s)thatIhave
chosenabove.
lIunderstand
thatImustm
eeteligibilityrequirem
entsforallcoverages
thatIhavechosen
above.
lIagree
thatmy
employerm
aydeductprem
iums
fromm
ypay
iftheyare
requiredforthe
coverageIhave
chosenabove.
lIacknow
ledgeand
consenttoreceiving
electroniccopies
ofapplicableinsurance
relateddocum
ents,inlieu
ofpapercopies,tothe
extentpermitted
byapplicable
law.I
may
changethis
electiononly
byproviding
thirty(30)day
priorwritten
notice.
lIattestthatthe
information
providedabove
istrue
andcorrectto
thebestofm
yknow
ledge.
Anyperson
who
with
intenttodefraud
anyinsurance
company
orotherpersonfiles
anapplication
forinsuranceorstatem
entsofclaim
containingany
materially,false
information
orconcealsforpurpose
ofmisleading
information
concerningany
factmaterialthereto,com
mits
afraudulentinsurance
act,which
isa
crime,and
may
alsobe
subjecttocivilpenalties,ordenialofinsurance
benefits.
Thestate
inw
hichyou
residem
ayhave
aspecific
statefraud
warning.Please
refertothe
attachedFraud
Warning
Statements
page.
Thelaw
sofNew
Yorkrequire
thefollow
ingstatem
entappear:Anyperson
who
knowingly
andw
ithintentto
defraudany
insurancecom
panyorotherperson
filesan
applicationforinsurance
orstatementofclaim
containingany
materially
falseinform
ation,orconcealsforthe
purposeofm
isleading,information
concerningany
factm
aterialthereto,comm
itsa
fraudulentinsuranceact,w
hichis
acrim
e,andshallalso
besubjectto
acivilpenalty
nottoexceed
fivethousand
dollarsand
thestated
valueofthe
claimforeach
suchviolation.(Does
notapplyto
LifeInsurance.)
SIGNATUREOF
EMPLOYEE
X___________________________________________
DATE______________________
EnrollmentKit
00475402,0001,EN
FraudW
arningStatem
ents
Thelaw
sofseveralstates
requirethe
following
statements
toappearon
theenrollm
entform:
Alabama:Any
personw
hoknow
inglypresents
afalse
orfraudulentclaimforpaym
entofaloss
orbenefitorwho
knowingly
presentsfalse
information
inan
applicationfor
insuranceis
guiltyofa
crime
andm
aybe
subjecttorestitution
finesorconfinem
entinprison,orany
combination
thereof.
Arizona:ForyourprotectionArizona
lawrequires
thefollow
ingstatem
enttoappearon
thisform
.Anyperson
who
knowingly
presentsa
falseorfraudulentclaim
forpayment
ofaloss
issubjectto
criminaland
civilpenalties.
California:ForyourprotectionCalifornia
lawrequires
thefollow
ingto
appearonthis
form:The
falsityofany
statementin
theapplication
shallnotbartherightto
recoveryunderthe
policyunless
suchfalse
statementw
asm
adew
ithactualintentto
deceiveorunless
itmaterially
affectedeitherthe
acceptanceofthe
riskorthe
hazardassum
edby
theinsurer.
Colorado:Itisunlaw
fultoknow
inglyprovide
false,incomplete,orm
isleadingfacts
orinformation
toan
insurancecom
panyforthe
purposeofdefrauding
orattempting
todefraud
thecom
pany.Penalties
may
includeim
prisonment,fines,denialofinsurance,and
civildamages.
Anyinsurance
company
oragentofaninsurance
company
who
knowingly
providesfalse,incom
plete,ormisleading
factsorinform
ationto
apolicy
holderorclaimantforthe
purposeofdefrauding
orattempting
todefraud
thepolicy
holderorclaimantw
ithregard
toa
settlementoraw
ardpayable
frominsurance
proceedsshallbe
reportedto
theColorado
DivisionofInsurance
within
theDepartm
entofRegulatory
Agencies.
Connecticut,Iowa,Nebraska,and
Oregon:Anyperson
who
knowingly,and
with
intenttodefraud
anyinsurance
company
orotherperson,filesan
applicationofinsurance
orstatementofclaim
containingany
materially
falseinform
ationorconceals,forthe
purposeofm
isleading,information
concerningany
factmaterialthereto,m
aybe
guiltyof
afraudulentinsurance
act,which
may
bea
crime,and
may
alsobe
subjecttocivilpenalties.
Delaware,Indiana
andOklahom
a:WARNING:Any
personw
hoknow
ingly,andw
ithintentto
injure,defraudordeceive
anyinsurer,m
akesany
claimforthe
proceedsofan
insurancepolicy
containingany
false,incomplete
ormisleading
information
isguilty
ofafelony.
DistrictofColumbia:W
ARNING:Itisa
crime
toprovide
falseorm
isleadinginform
ationto
aninsurerforthe
purposeofdefrauding
theinsurerorany
otherperson.Penaltiesinclude
imprisonm
entand/orfines.Inaddition,an
insurermay
denyinsurance
benefits,iffalseinform
ationm
ateriallyrelated
toa
claimw
asprovided
bythe
applicant.
Florida:Anyperson
who
knowingly
andw
ithintentto
injure,defraud,ordeceiveany
insurerfilesa
statementofclaim
oranapplication
containingany
false,incomplete,or
misleading
information
isguilty
ofafelony
ofthethird
degree.
4
Kansas:Anyperson
who
knowingly,and
with
intenttodefraud
anyinsurance
company
orotherperson,filesan
applicationofinsurance
orstatementofclaim
containingany
materially
falseinform
ationorconceals,forthe
purposeofm
isleading,information
concerningany
factmaterialthereto,m
aybe
guiltyofinsurance
fraudas
determined
bya
courtoflaw.
Kentucky:Anyperson
who
knowingly
andw
ithintentto
defraudany
insurancecom
panyorotherperson
filesa
statementofclaim
containingany
materially
falseinform
ationorconceals,forthe
purposeofm
isleading,information
concerningany
factmaterialthereto
comm
itsa
fraudulentinsuranceact,w
hichis
acrim
e.
Louisianaand
Texas:Anyperson
who
knowingly
presentsa
falseorfraudulentclaim
forpaymentofa
lossorbenefitis
guiltyofa
crime
andm
aybe
subjecttofines
andconfinem
entsin
stateprison.
Maine,Tennessee
andW
ashington:Itisa
crime
toknow
inglyprovide
false,incomplete
ormisleading
information
toan
insurancecom
panyforthe
purposeofdefrauding
thecom
pany.Penaltiesm
ayinclude
imprisonm
ent,finesora
denialofinsurancebenefits.
Maryland
:Anyperson
who
knowingly
orwillfully
presentsa
falseorfraudulentclaim
forpaymentofa
lossorbenefitorknow
inglyorw
illfullypresents
falseinform
ationin
anapplication
forinsuranceis
guiltyofa
crime
andm
aybe
subjecttofines
andconfinem
entinprison.
RhodeIsland:Any
personw
hoknow
inglyand
willfully
presentsa
falseorfraudulentclaim
forpaymentofa
lossorbenefitorknow
inglyand
willfully
presentsfalse
information
inan
applicationforinsurance
isguilty
ofacrim
eand
may
besubjectto
finesand
confinementin
prison.
Minnesota:A
personw
hofiles
aclaim
with
intenttodefraud
orhelpscom
mita
fraudagainstan
insurerisguilty
ofacrim
e.
NewHam
pshire:Anyperson
who,w
itha
purposeto
injure,defraudordeceive
anyinsurance
company,files
astatem
entofclaimcontaining
anyfalse,incom
pleteor
misleading
information
issubjectto
prosecutionand
punishmentforinsurance
fraud,asprovided
inN.H.Rev.Stat.Ann.§
638:20
NewJersey:Any
personw
hoknow
inglyfiles
astatem
entofclaimcontaining
anyfalse
ormisleading
information
issubjectto
criminaland
civilpenalties.
NewM
exico:Anyperson
who
knowingly
presentsa
falseorfraudulentclaim
forpaymentora
lossorbenefitorknow
inglypresents
falseinform
ationin
anapplication
forinsurance
isguilty
ofacrim
eand
may
besubjectto
civilfinesand
criminalpenalties
ordenialofinsurancebenefits.
Ohio:Anyperson
who
with
intenttodefraud
orknowing
thathe/sheis
facilitatinga
fraudagainstan
insurer,submits
anapplication
orfilesa
claimcontaining
afalse
ordeceptive
statementis
guiltyofinsurance
fraud.
Pennsylvania:Anyperson
who
knowingly
andw
ithintentto
defraudany
insurancecom
panyorotherperson
filesan
applicationforinsurance
orstatementofclaim
containingany
materially
falseinform
ationorconceals
forthepurpose
ofmisleading,inform
ationconcerning
anyfactm
aterialtheretocom
mits
afraudulentinsurance
act,w
hichis
acrim
eand
subjectssuch
personto
criminaland
civilpenalties.
Vermont:Any
personw
hoknow
inglypresents
afalse
statementin
anapplication
forinsurancem
aybe
guiltyofa
criminaloffense
andsubjectto
penaltiesunderstate
law.
Virginia:Anyperson
who
with
intenttodefraud
orknowing
thathe/sheis
facilitatinga
fraudagainstan
insurer,submits
anapplication
orfilesa
claimcontaining
afalse
ordeceptive
statementm
ayhave
violatedstate
law.