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

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NTIR

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MP

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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

qq

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

qq

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

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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.