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I wish to remain Anonymous Citizen Insurance Professional Insurer Law Enforcement SIU Member State/Federal Agency   Please provide a brief summary of the facts of this matter: Reporting Individual Information Last Name: First Name: Middle Name: Office Telephone: - - Fax Telephone: - - E-Mail Address: Mailing Address: City: State: Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming ZIP Code: Policy Information Policy Number: Name of Insurance Carrier: Office Telephone: - - Fax Telephone: - - E-Mail Address: Mailing Address: City: State: Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming ZIP Code: Insured Information Last Name or Business Name: First Name: Middle Name: Mailing Address: City: State: Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming ZIP Code: Claim Information Claim Number: Date of Claim: January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2017 2018 2019 2020 2021 2022 2023 2024 City of Claim: State of Claim: Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Total Approximate Claim Amount: $ Have any payments been made on this claim? Yes    No If Yes Total Amount Paid: $ Amount of Unpaid Claim Suspected    to be fraudulent: $  Amount of Paid Claim Suspected    to be fraudulent: $ Is claim still active? Yes    No If No was claim denied?: Yes    No Was claim withdrawn by claimant?    Yes   No  If Yes Explain Briefly: Was a written claim filed?   Yes    No If Yes was it:    Mailed   Submitted in Person Was the claim filed by telephone?    Yes   No If Yes Was it recorded?   Yes No Were any forms or payments on this claim sent through the mail?   Yes    No Was a proof of loss submitted?       Yes    No   If Yes Was it notarized?  Yes No Claimant Information Or person being reported if different from insured. Last Name or Business Name:   First Name:   Middle Name:   Mailing Address:   City:   State: Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming ZIP Code:  Line of Business/ Coverage Information Select all that apply Property Fraud Motor Vehicle/ Auto Homeowners Commercial Other     Property Damage     Property Damage     Property Damage     Stolen Vehicle     Theft/Loss     Theft/Loss     Other (Explain)      Other (Explain)      Other (Explain)  Bodily Injury/Casualty Motor Vehicle/ Auto Homeowners Commercial Workers Comp     Medical Payments     Personal Injury     Personal Injury Other     Other (Explain)      Other (Explain)      Other (Explain)  Describe the Nature of Suspected Fraudulent Activity Select all that apply    Faked/ Exaggerated Property Damage   Inflated Financial Loss   Staged Accident/Injury    Faked/ Exaggerated Injury   Previous Fraudulent Claims   Organized/ Ring Activity    Suspected Arson   Faked/ Exaggerated Property Theft or Loss   Other (Explain)           What information has been developed to confirm your suspicion? Select all that apply    Witnesses Photographs Videos Multiple Claims for Same Loss    Investigative Reports Medical Reports Audio Tapes Correspondence    Conflicting         Statements Depositions/       Sworn Testimony Falsified       Documents Claimant Lied Under Oath   Other (Explain)           Has this incident been reported to any other agency/organization? Yes    No If yes, select all that apply    Insurance Company SIU    NICB Other State Fraud Unit   Other Law Enforcement Agency  ( Please Identify )

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