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Group Claim Fraud Statement

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Group Claim Fraud Statements / Life Waiver of Premium Form / Attending Physician’s Statement

The following fraud language is attached to, and made part of this claim form. Please read and do not remove these pages from this claim form.

Alaska: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law.

Arizona: 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.

Arkansas or Louisiana: 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.

California: For your protection California law requires the following to appear on this form. Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement 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, fines, denial of insurance and civil damages.

Delaware: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony.

District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines.

Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

Idaho: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony.

Indiana: 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.

Kentucky: 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.

Maine, Tennessee or Virginia: 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, fines and a denial of insurance benefits.

Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

New Hampshire: 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.

New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

New Mexico: 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 CIVIL FINES AND CRIMINAL PENALTIES.

New York: 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 INSURANCE ACT, WHICH IS A CRIME AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION. (PURSUANT TO 11 NYC RR86)

Ohio: 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.

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.

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

Texas: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

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, fines and denial of insurance benefits.

If you live in a state other than mentioned above, the following statement applies to you: Any person who knowingly, and with intent to injure, defraud or deceive any insurer or insurance company, files a statement of claim containing any materially false, incomplete, or misleading information or conceals any fact material thereto, may be guilty of a fraudulent act, may be prosecuted under state law and may be subject to civil and criminal penalties. In addition, any insurer or insurance company may deny benefits if false information materially related to a claim is provided by the claimant.

Life Waiver of Premium Form

United of Omaha Life Insurance Company

Home Office - Omaha, Nebraska

Statement of Claim for Continuance of Life Insurance Protection During Total Disability

Please return completed form to: United of Omaha Life Insurance Company, Group Life Claims, Mutual of Omaha Plaza, Omaha, Nebraska 68175, Toll Free 1-800-775-8805

To Be Completed By Insured

The insured or guardian is responsible for completion of this proof without expense to the Company. The Company, in furnishing this form, does so without admitting any liability or waiving any of its rights under the policy on which this claim is made.

Describe disability

If “Yes,” give type of work and name and address of your employer.

Name below all physicians who have treated you since that date (may be contacted to obtain medical information): Dates of treatment

In your opinion, are you now wholly unable to engage in any and all work and every occupation or business?

Have you applied for, or are you receiving benefits from:

a) Social Security

b) LTD Insurance

Please send copies of any letters or notices approving or denying benefits.

To Be Completed by Master Policyholder or Group Administrator (please type)

We hereby certify that, to the best of our knowledge and belief, the above statements are correct

Authorization To Disclose Personal Information

To physicians, medical or dental practitioners, hospitals, clinics, pharmacies, pharmacy benefit managers, other medical care facilities, health maintenance organizations, insurers, employers, consumer reporting agencies and all other providers of medical or dental services.

I authorize you to release to representatives of United of Omaha Life Insurance Company, personal information about me including: medical history, mental and physical condition, prescription drug records, alcohol or drug use, financial and occupational information in order to evaluate my claim for benefits.

If the person or entity to whom information is disclosed is not a health care provider or health plan subject to federal privacy regulations, the information may be redisclosed without the protection of the federal privacy regulations.

I understand that I may refuse to sign this authorization. I realize that if I refuse to sign, my claim for benefits may not be paid.

This authorization will expire 24 months after the date signed. I may revoke this authorization at any time by written notice to; ATTN: Group Life Claims, United of Omaha Life Insurance Company, Mutual of Omaha Plaza, Omaha, NE 68175-0001. Any revocation of this authorization will not affect any use or disclosure of Personal Information that occurred prior to the receipt of my revocation.

I understand that I am entitled to receive a copy of the authorization and that a copy is as valid as the original.

Name(s) used for medical records (if different than the name below):

If Applicable: I am the legal representative of the person whose Personal Information is to be disclosed, and I am authorized to grant permission on behalf of that person.

Attending Physician’s Statement

This form is to be completed without expense to United of Omaha Life Insurance Company. Additional space is provided on the reverse side for comments.

5. Frequency of visits?

6. Diagnosis: (Include any complications)

7. Subjective Symptoms:

8. CARDIAC. (If applicable)

a) Functional capacity (American Heart Association)

b) Blood Pressure (last visit)

/

9. Physical Impairment (* as defined in Federal Dictionary of Occupational Titles)





Remarks:

10. Mental/Nervous Impairment (if applicable)

a) Please define “stress” as it applies to this claimant.

b) What stress and problems in interpersonal relations has claimant had on job?





Remarks:

11. PROGRESS

a) Patient is:

b) Patient is:

Please answer questions 12 and 13 for both occupational categories

Regular Occupation
Any Occupation
12. Is patient now totally disabled?
Date patient was released to return to work:
13. Approximate date patient may resume work in either occupational category:
If date unknown, please select one of the adjacent classifications in each category.

14. What restrictions, if any, would be placed upon patient’s return to work?

15. Remarks:

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What a Group Claim Fraud Statement Is and When It’s Used

A Group Claim Fraud Statement is a written, signed declaration used by employers, benefit administrators, insurers, or third-party administrators to report suspected coordinated or organized fraud affecting multiple claimants or a single group policy. The form documents factual details, dates, and supporting evidence and records the declarant’s signature under penalty of perjury or applicable statutory penalty language. It is used to trigger internal investigations, insurer claim reviews, subrogation and recovery processes, and potential referral to law enforcement or regulatory agencies.

Why the Group Claim Fraud Statement Matters

A clear fraud statement preserves factual detail, supports timely investigations, and creates an auditable record for claims adjudication and legal action.

Why the Group Claim Fraud Statement Matters

Who Completes and Signs a Group Claim Fraud Statement

Typical filers include plan administrators, insurance investigators, employer HR or benefits teams, and compliance officers.

  • Employer compliance officer or HR representative with direct case knowledge and access to payroll or attendance records.
  • Insurer or TPA investigator assigned to the claim who can supply claim file references and supporting documents.
  • Legal or fraud unit designee authorized to escalate matters to law enforcement or regulatory bodies.

The statement should be completed by someone with direct knowledge of the allegation and authority to represent the reporting organization.

Essential Elements of a Professional Group Claim Fraud Statement

A well-structured statement groups the incident facts, affected parties, claim references, supporting evidence, and declarant details so investigators can act without needing immediate follow-up.

Incident summary

Concise factual description of the suspected fraud event, dates, locations, and sequence of actions relevant to the group claim.

Affected parties

List of individuals, policy numbers, employer units, or membership groups impacted, with identifiers such as claim numbers or participant ID.

Evidence inventory

Catalog of documents, photos, emails, payroll records, witness statements, and system logs that support the allegation.

Statements under penalty

Declarant language asserting truthfulness and legal consequences for false statements, tailored to jurisdictional standards.

Signatory block

Name, title, organization, contact information, signature, and date; corporate signers indicate authority or job role.

Referral history

Record of internal referrals, prior actions taken, and any law enforcement or regulator notifications.

Required Data Elements to Include

Declarant name: Full legal name
Declarant title: Job title/role
Organization: Employer or insurer name
Claim references: Policy or claim numbers
Event dates: MM/DD/YYYY format
Attachment list: Evidence filenames

Step-by-Step: Completing a Group Claim Fraud Statement

Follow these steps in order to prepare a clear, complete, and actionable statement for investigator review.

  • 01
    Gather evidence: Collect payroll, claims, correspondence, and system logs that support the allegation.
  • 02
    Identify affected group: List the group, plan, or policy IDs and all implicated claim numbers.
  • 03
    Draft facts: Summarize events chronologically with dates and locations.
  • 04
    Sign and submit: Sign the statement and route it to the insurer, TPA, or compliance unit per policy.

Configuring an Online Workflow for Submission and Review

Set up fields, authentication, routing, and retention to match your internal escalation and compliance needs.

Field Configuration
Signature field Required, signer name and date auto-filled
Authentication Email + SMS code or enterprise SSO
Routing Sequential: investigator → manager → legal
Retention policy Apply legal hold and archival rules

Where to Send and How the Statement Is Processed

A standard routing path ensures prompt review and creates an audit trail for compliance or legal referral.

  • Submit to TPA: Email or upload to the third-party administrator’s secure portal.
  • Assign investigator: Investigator receives intake and evidence package automatically.
  • Internal review: Claim team assesses for denial, subrogation, or escalation.
  • Law enforcement referral: If warranted, case is referred with supporting materials.

Digital Submission and Signing: Technical Considerations

Use secure e-signature and secure file transfer when submitting statements electronically to preserve chain of custody.

  • File formats: PDF preferred for fixed record
  • Authentication: Email + SMS code or stronger
  • Audit trail: IP, timestamp, and action log

Timelines and Response Expectations

Understand internal and statutory timelines so investigations and referrals meet compliance deadlines and preserve rights.

Initial intake response:

Acknowledge receipt within 3–5 business days.

Preliminary investigation:

Complete initial fact-gathering within 15–30 business days.

Full investigation:

Expect 30–90 day cycles for complex group matters.

Regulator notification:

Notify regulators per policy or state requirements promptly.

Record retention start:

Retention clock begins on statement creation date.

Common Legal and Operational Risks

Incomplete facts: Delays investigations
Wrong signatory: Questioned authority
Missing evidence: Weakens legal standing
Improper disclosure: HIPAA or privacy breach risk
False allegation: Exposure to defamation or penalties
Late filing: Loss of subrogation rights

eSignature Pricing and Compliance Snapshot (signNow first)

Basic pricing and feature availability across common eSignature vendors. Confirm specific plan terms and HIPAA BAA details directly with each vendor.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial Yes, 7-day free trial No No No No
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes (BAA) Yes Yes No No

How Group Claim Fraud Statements Differ from Individual Claim Affidavits

Compare form scope, evidence needs, and typical procedural differences to choose the correct intake path.

Criteria Group Claim Statement Individual Claim Affidavit
Primary scope multiple claimants single claimant
Typical notarization optional or ron permitted often notarized
Evidence volume high; multiple records focused; claimant documents
Investigation route fraud unit or special team standard claim adjuster

Real-World Examples of Electronic Fraud Statement Use

Two organizations describe how digital intake and signed statements supported investigations and record preservation.

Fertility Centers of Illinois

A centralized fraud report consolidated multiple suspicious billing entries into one investigation package.

  • Investigation team used the statement to link claims across providers.
  • "The airSlate SignNow team has been exceptional, responsive, the API has been great, and we're extremely happy that we chose airSlate SignNow as a company."

Tech Data

Corporate benefits team submitted a single group allegation covering an employee cohort.

  • The statement accelerated subrogation assessment.
  • "Tech Data uses airSlate SignNow to improve our internal and external customer service while increasing our speed to revenue."

Practical Tips to Improve Accuracy and Speed

Adopt consistent formats, secure transmission, and clear signatory authority to reduce processing friction and legal exposure.

Use standard identifiers
Always include policy numbers, claimant IDs, and exhibit labels. This prevents misrouting and ensures investigators can match attachments to the statement immediately.
Record chain of custody
Log who collected each piece of evidence and when. A clear custody trail strengthens admissibility and supports subrogation or prosecution.
Limit PHI exposure
Redact unnecessary protected health information and transmit materials under a BAA-compliant process to limit HIPAA risk during external sharing.
Use strong authentication
Require at least two-factor signer authentication or enterprise SSO for corporate declarants to reduce repudiation and impersonation risk.

Key Processing Milestones from Intake to Closure

Sequential milestone stages help teams track progress and meet statutory or policy deadlines during investigations.

01

Intake logged

Intake acknowledged and evidence uploaded within 3–5 days

02

Preliminary review

Investigative triage and priority decision within 15–30 days

03

Formal investigation

Detailed analysis and interviews completed in 30–90 days

04

Resolution and records

Closure, recovery actions, and archival per retention rules

Frequently Asked Questions and Troubleshooting

Answers to common questions about preparing, signing, and submitting Group Claim Fraud Statements to reduce processing delays and legal risk.


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