DEPARTMENT OF INSURANCE
Uniform Suspected Insurance Fraud Reporting Form
(We can only open a case of fraud based on the information you provide. If our office has questions and cannot contact you for answers, we will have to close the referral for insufficient evidence.)
Reporting Person Details
Prefix
First Name
Mid Name
Last Name
Suffix
Email
Phone Number
Extension
Fax
Reporting Person Address
Address Type
Address Line1
Address Line2
Address Line3
Postal Code
State
City
County
Detailed Synopsis
1) What is the specific allegation of fraud? *
2) Documentation / evidence to substantiate allegation of fraud
Other Description
Dates of Fraud From
To
Description of Fraud
Loss Details
Date of Loss / Injury
Loss Type
If Other,(*) enter description
Address of Loss/Injury
Postal Code
State
City
County
Civil Litigation Pending
Claim #
Insurance Type
Reserve Amount
Amount Paid
Date Paid
Loss Amount
Settlement Amount
Settlement Amt Paid Date
Other Suspected Fraudulent Activity
Is there any reason to believe that this incident is related to other suspected fraudulent activity?
If Yes, Enter details
Upload documentation
Attach additional documentation / evidence. Please only use pdf, jpg, gif, png, doc, txt. (Maximum file size is 20MB, multiple files can be uploaded)
Upload

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