By submitting this form, I affirm that all of the information supplied in this form is complete, true, and correct, and submitted for the purpose of aiding Agents National Title Insurance Company in its administration of my claim.
For policies insuring title to Alabama or Texas land: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit is guilty of a crime and may be subject to restitution, fines, or confinement in prison, or any combination thereof.
For policies insuring title to Alaska, Delaware, Florida, Idaho land: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information is guilty of a felony and may be prosecuted under state law.
For policies insuring title to Arkansas, Louisiana, New Mexico, Rhode Island land: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison
For policies insuring title to Arizona land: 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.
For policies insuring title to Colorado land: 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, fines, 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.
For policies insuring title to Indiana land: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony.
For policies insuring title to Kentucky land: Any person who knowingly and with intent to defraud any insurance company or other person files a 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.
For policies insuring title to Maine, Tennessee, Virginia, or Washington land: “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, fines or a denial of insurance benefits.”
For policies insuring title to Maryland or Oregon land: “Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.”
For policies insuring title to Minnesota land: “A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.”
For policies insuring title to New Hampshire land: “Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.”
For policies insuring title to New Jersey land: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.
For policies insuring title to Ohio land: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
For policies insuring title to Oklahoma land: 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.
By selecting “Submit,” I am signing this form electronically.