Please review the important (state-specific) information below, click “I Accept” at the bottom of this page to return to the online form. Complete and submit the subsequent form. By clicking on “I Accept” and filling out the appropriate form, you are stating that you understand your state-specific laws and are willing to proceed. If you don’t see your state below, click on “I accept” to proceed with reporting your claim.
Alaska
A person who knowingly and with intent to injure, defraud or deceive and insurance company files a claim containing false, incomplete of 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, Connecticut, Delaware, District of Columbia, Kentucky, Louisiana, Maine, Michigan, New Jersey, New Mexico, New York, North Dakota, Pennsylvania, South Dakota, Tennessee, Texas, Virginia, Washington and West Virginia
Any person who knowingly and with intent to defraud any insurance company or another 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, subject to criminal prosecution and [NY: substantial] civil penalties. In DC, LA, ME, TN, VA and WA, insurance benefits may also be denied.
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 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. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder 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 and Idaho
Any person who knowingly and with the intent to injure, defraud, or deceive any insurance company files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.*
*In Florida – Third Degree Felony
Hawaii
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.
Indiana
For your protection, Indiana law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.
Minnesota
A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
Nevada
Pursuant to NRS 686A.291, any person who knowingly and willfully files a statement of claim that contains any false, incomplete or misleading information concerning a material fact is guilty of a felony.
New Hampshire
Any person who, with 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 York
Any person who knowingly and with intent to defraud any insurance company or other person files an application for commercial insurance or a statement of claim for any commercial or personal insurance benefits containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person who in connection with such application or claim knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the Department of Motor Vehicles or an insurance company, commits a fraudulent insurance act, which is a crime, and shall also be subject to civil penalty not to excess five thousand dollars and the value of the subject motor vehicle or stated claim for each violation.
Ohio
Any person who, with intent to defraud or knowing that he/she 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.
Welcome to the Continental Western Group® E-Pay Express online bill payment services website, which provides bill payment options and services (such website, options, and services are individually and collectively referred to herein as the “E-Pay Express Services”) available to customers of the Continental Western Group®, an operating unit of Berkley Insurance Company, and affiliated companies (referred to herein as “OU acronym, i.e. “CWG”). CWG® is willing to provide the E-Pay Express Services to you, a customer of CWG, only upon your agreement that your access to and use of the E-Pay Express Services will be subject to the following E-Pay Express Terms of Service Agreement (the “Agreement”). This Agreement describes the terms and conditions under which CWG will make E-Pay Express Services available to CWG’s customers (“you”). The Agreement may be revised without notice and will become effective upon posting on this site and your use of the E-Pay Express Services.I. DEFINITIONSThe following defined terms are used in this Agreement: E-Pay Express is a service you can use to view and pay your CWG bill online securely. CWG has licensed the right to use E-Pay Express from an unaffiliated third party, Fifth Third Bank. and/or its affiliates (“Fifth Third”). Account means the Account with CWG to which you authorize a bill payment to be directed. Payment Instruction means your instruction and authorization to E-Pay Express to make a bill payment to your Account. Payment Account means the bank account that you authorize E-Pay Express to debit when you make your bill payment using account information from your personal or business checking or savings account. Payment Card means the credit or debit card that you instruct E-Pay Express to charge to pay your bill payment. Business Day means Monday through Friday, excluding Federal Reserve holidays. Scheduled Payment Date means the Business Day of your choice upon which E-Pay Express will attempt to complete your bill payment and initiate the appropriate debit to your Payment Account or Payment Card. CWG includes the following affiliated companies of Berkley Insurance Company: Acadia Insurance Company, Continental Western Insurance Company, Firemen’s Insurance Company of Washington, D.C., Tri-State Insurance Company of Minnesota, Union Insurance Company (collectively referred to herein as “Insurers”). All payments processed through E-Pay Express Services are paid to CWG on behalf of itself or one of the Insurers listed above; however, each of the Insurers has sole financial responsibility for its own products and services, including the E-Pay Express Services provided in connection with those products and services. You should refer to your insurance policy for the applicable Insurer.II. DESCRIPTION OF E-PAY EXPRESS SERVICES A. The E-Pay Express Services provide you with access to various online resources, including applications that allow you to view your CWG bill. Unless explicitly stated otherwise, any new features that augment or enhance the current E-Pay Express Services, including the release of new services, shall be subject to this Agreement. Upon your acceptance of this Agreement, CWG grants you a personal, nonexclusive, non-transferable license to access and use the E-Pay Express Services, subject to this Agreement, solely for the purpose of viewing and paying your Account electronically. The foregoing license includes the specific rights to use the available applications and functionalities of the E-Pay Express Services and to print information from the E-Pay Express Services. CWG and Fifth Third do, however, reserve the right to, without notice: (a) modify, suspend or terminate operation of or access to the E-Pay Express Services at any time for any reason; (b) modify or change the E-Pay Express Services or its applicable operating policies at any time; and (c) interrupt the E-Pay Express Services as necessary to perform routine and non-routine maintenance, error corrections, or other changes. CWG also reserves the right to modify this Agreement at any time, in which case you will be provided notice that the Agreement has been changed. Your continued use of the E-Pay Express Services after said notice of the changed Agreement constitutes your agreement with and acceptance of the changed Agreement.
BILL PAYMENT SERVICE
(a) When you initiate a Payment Instruction, you authorize E-Pay Express to charge your Payment Card or debit your Payment Account and remit funds to CWG on your behalf so that the funds arrive to pay your bill as close to the Business Day designated by you as is reasonably possible. While it is anticipated that most transactions will be processed on the day you choose, it is understood that due to circumstances beyond the control of CWG and Fifth Third, some transactions may take a day or so longer to be credited to your Account.(b) If E-Pay Express is unable to obtain funds for a bill payment for any reason associated with your Payment Card or Payment Account (for example, there is not a sufficient balance available on your Payment Card or in your Payment Account to cover the transaction), then we will not be able to complete your bill payment transaction. If there is a problem in processing your Payment Instruction, CWG or Fifth Third may attempt to contact you, using the telephone number you have provided(c) If E-Pay Express makes a bill payment to your Account, but is unable to obtain funds for that payment from your Payment Card or Payment Account, you agree that your bill payment will be reversed.III. LIABILITY FOR FAILURE TO COMPLETE TRANSACTIONSA. E-Pay Express will use commercially reasonable efforts to process your bill payments in accordance with your Payment Instructions. However, CWG and Fifth Third shall incur no liability if a bill payment is not made in a timely manner or if any payments initiated by you through the E-Pay Express Services cannot be completed because of any one or more of the following circumstances:
Sufficient funds are not available through your Payment Account or your Payment Card;
Any failure on the part of CWG or Fifth Third to account correctly for or credit the payment in a timely manner, or any other mishandling of your payment by CWG or Fifth Third;
The E-Pay Express Services are not working properly and you know or have been advised by CWG or Fifth Third about the malfunction before you execute the transaction;
You do not provide CWG or Fifth Third with all required information to complete the bill payment, such as your correct name, telephone number, or your complete and correct Payment Card or Payment Account information; or
Circumstances over which CWG or Fifth Third have no control include, but are not limited to, large-scale technical malfunctions, including, but not limited to, loss of access to the Internet or loss of access to the Federal Reserve System, prolonged outages of telephone lines, electricity or similar infrastructure, acts of God, war, riot, civil disobedience or similar events of insurrection, governmental or court orders, regulatory or legislative changes by any local, state or federal governmental agency, strikes, work stoppages or other similar occurrences or circumstances.
IV. USER NAMES AND PASSWORDSA. During the registration process for the E-Pay Express Services, a User Name, and Password (collectively, “Authentication Materials”) will be established for your use in accessing the E-Pay Express Services. The Authentication Materials are intended for your use only. You agree: (a) not to disclose such Authentication Materials to any third party, (b) to take reasonable care to protect such Authentication Materials from inadvertent disclosure to third parties, and (c) to immediately notify CWG of any loss or unauthorized use of such Authentication Materials. You agree that you will be responsible for all actions taken using your Authentication Materials.V. YOUR REPRESENTATIONS.A. You hereby represent to CWG and agree that:
any and all information that you provide to CWG or Fifth Third to use the E-Pay Express Services will be accurate and complete;
you will not use the E-Pay Express Services to access information about any account unless you have authority to do so by the person or company whose account you are accessing;
you will not provide any information to CWG or Fifth Third or in your use of the E-Pay Express Services, including account information unless you have the authority to communicate such information;
you will not use the E-Pay Express Services for any illegal or improper purposes;
you will not use: (i) any robot, spider, other automatic device to monitor or copy portions of the E-Pay Express home page or the E-Pay Express Services or the content contained therein, or (ii) any device, software, or routine to interfere or attempt to interfere with the proper working of the Payer Express home page or the E-Pay Express Services;
you will not download, reproduce, duplicate, copy or otherwise extract any portion of the E-Pay Express home page or the E-Pay Express Services for the purpose of sale or resale, or make other commercial use thereof, and
CWG or Fifth Third may send you electronic correspondence describing changes to the E-Pay Express Services and this Agreement.
Please Note: Colorado Form WC 50 requires the name of your Insurer to be included on the Form prior to posting at your location(s). You can locate the name of your Insurer here on your policy.
Agency of Oversite: Wyoming Department of Workforce Services Workers’ Compensation Division
Posting Notice: Certificate of Good Standing Required
Addional Posting Information: Any business conducting work in the State of Wyoming or hiring a Wyoming resident as an employee must register with the Division of Workers’ Compensation and Unemployment Insurance.
Agency of Oversite: Missouri Division of Workers Compensation 2
Posting Notice: Workplace Poster Required
Addional Posting Information: The forms are mandatory in both English and Spanish. The forms must be posted proximately to each other. The forms are also available in two sizes—poster and letter size.
Agency of Oversite: Michigan Workers Compensation Agency
Posting Notice: No Poster Required
Addional Posting Information: There is currently no requirement for the posting of a workers compensation insurance notice by the state of Michigan. But there are two posters that an employer may voluntarily post in the workplace.
Agency of Oversite: Iowa Division of Workers Compensation
Posting Notice: No Poster Required
Addional Posting Information: There is no posting notice requirement for employers that have secured workers compensation coverage or qualified as a selfinsurer. Only employers who have failed to secure coverage for the liabilities assumed under the Act must post a notice of the failure to insure.
