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I understand that if I or my dependents provide false information to the Boilermakers National Health & Welfare Fund or conceal information, we could be subject to severe penalties under state and federal law and the Fund may seek to recover benefits wrongfully paid or pursue legal remedies against us. I declare under penalty of perjury that the foregoing is true and correct. I agree, for myself and my dependents, that in the event any health care services are the primary responsibility of any other party by way of other group health coverage or by the act of omission of another person to fully inform Boilermakers National Health & Welfare Fund and that I will execute such assignments, liens or other documents which may be necessary to enable Boilermakers National Health & Welfare Fund to recover the value of benefits provided. I further agree that in the event I or any of my dependentscollect benefits or damages from any other party who has primary responsibility for services provided, I will immediately reimburse Boilermakers National Health & Welfare Funds to the extent of services provided and to the extent specified by the plan. FRAUD WARNING Any person who, knowingly and with intent to defraud the Fund or other person: (1) files an application for benefits or statement of claim containing any materially false information; or (2) conseals for the purpose of misleading, information concerning any material fact hearto, commits, a fraudulent act and may be subject to legal action.
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