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OUT-OF-NETWORK VISION SERVICES CLAIM FORM
State Fraud Warning Statements
General Fraud Warning: Any person who knowlingly and with intent to injure, defraud or deceive any insurance company or other person les 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.
Alabama: Any person who knowingly presents a false or fraudulent claim for payment of loss or benet or who knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to restitution nes
or connement in prison, or any combination thereof. Arkansas, District of Columbia, Rhode Island, West Virginia: Any person who
knowingly presents a false or fraudulent claim for payment of loss or benet or knowingly presents false information in an application for insurance
is guilty of a crime and may be subject to nes and connement in prison. California: For your protection, California law requires the following to
appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to
nes and connement in state 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, nes, 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. Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer les a statement of claim or an
application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Kansas: Any person who with
intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or les a claim containing a false or
deceptive statement may be guilty of insurance fraud as determined by a court of law. Kentucky: Any person who knowingly and with intent to
defraud any insurance company or other person les a statement of claim containing any materially false information or conceals, for the purpose
of misleading, information concerning any fact material there to commits a fraudulent insurance act, which is a crime. Louisiana: Any person who
knowingly presents a false or fraudulent claim for payment of loss or benet or knowingly presents false information in an application for insurance
is guilty of a crime and may be subject to nes and connement in prison. Maine and 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 may include imprisonment,
nes or a denial of insurance benets. Maryland: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss
or benet or who knowingly and willfully presents false information in an application for insurance is guilt
y of a crime and may be subject to nes
and connement in prison. Missouri: 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, nes, denial of insurance and civil damages, as determined by a court of
law. Any person who knowingly and with intent to injure, defraud or deceive an insurance company may be guilty of fraud as determined by a
court of law. New Jersey: Any person who includes any false or misleading information on an application for an insurance policy or knowingly les
a statement of claim containing any false or misleading information is subject to criminal and civil penalties. New York: Any person who knowingly
and with intent to defraud any insurance company or other person les an application for insurance or statement of claim containing any materially
false information, or conceals for the purpose of misleading, information concerning any material fact material thereto, commits a fraudulent
insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed ve thousand dollars and the stated value of the claim for
each such violation. North Carolina: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other
person les an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of
misleading, information concerning any material fact material thereto commits a fraudulent insurance act, which may be a crime and subjects such
person to criminal and civil penalties. Ohio: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer,
submits an application or les a claim containing a false or deceptive statement is guilt
y of insurance fraud. 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. Oregon: Any person who with intent to injure, defraud, or deceive any insurance
company or other person submits an enrollment form for insurance or statement of claim containing any materially false information or conceals
for the purpose of misleading, information concerning any fact material thereto may have violate state law. Pennsylvania: Any person who
knowingly and with intent to defraud any insurance company or other person les 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 benet, 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 ne of not less than ve thousand ($5,000) and not more than ten thousand
($10,000), or a xed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present, the penalty thus
established may be increased to a maximum of ve (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two
(2) years. Texas: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or other person les an
application for insurance or statement of claim containing any intentional misrepresentation of material fact or conceals, for the purpose of
misleading, information concerning any fact material thereto may commit a fraudulent insurance act, which may be a crime and may subject such
person to criminal and civil penalties. Vermont: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company
or other person les 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 may be a crime and may subject such
person to criminal and civil penalties. Virginia: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or
other person les 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 act, which is a crime and subjects such person to criminal and
civil penalties. 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, nes, and denial of insurance benets.