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PLEASE READ: CRIMINAL PENALTY FOR PRESENTING FRAUDULENT CLAIM OR MAKING FALSE STATEMENTS

1. For Claims Originating in Missouri:

   For your protection, Missouri law requires the following to appear on this form:

   (a) It is unlawful to:

   1. Knowingly present or cause to be presented any false or fraudulent claim for the payment of a loss, including payment of a loss under a contract of insurance.
   2. Knowingly present multiple claims for the same loss or injury, including presentation of multiple claims to more than one insurer, with an intent to defraud.
   3. Knowingly cause or participate in a vehicular collision, or any other vehicular accident, for the purpose of presenting any false or fraudulent claim.
   4. Knowingly prepare, make or subscribe any writing with intent to present or use the same, or to allow it to be presented, in support of any such claim.

   (b) Every person who violates any provision of this section is punishable by imprisonment in the state prison for two, three or four years, or by a fine not exceeding ten thousand dollars, ($10,000), or both.

2. For Claims Originating in Missouri:

   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 act, which is a crime, and subjects such person to criminal and civil penalties.