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Penalties include imprisonment fines and denial of insurance benefits. Dated at this day of Witness Signature Signature Witness Name and Address Spouse Signature if both are Beneficiaries DCL-10-07/09 VA. This authorization is valid from the date signed for the duration of the claim. The following statement is made in accordance with Insurance Laws It is a crime to knowingly provide false incomplete or misleading information to an insurance company for the purpose of defrauding the company....
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