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:
ZIP Code:
Policy Information
Policy Number:
Name of Insurance Carrier:

Office Telephone: - -
Fax Telephone: - -
E-Mail Address:

Mailing Address:
City:
State:
ZIP Code:
Insured Information
Last Name or Business Name:
First Name:
Middle Name:

Mailing Address:
City:
State:
ZIP Code:
Claim Information
Claim Number:
Date of Claim:

Total Approximate Claim Amount: $

Have any payments been made on this claim?
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?
If No was claim denied?:

Was claim withdrawn by claimant?   
 If Yes Explain Briefly:

Was a written claim filed?  
If Yes was it:   

Was the claim filed by telephone?   
If Yes Was it recorded?  

Were any forms or payments on this claim sent through the mail?  

Was a proof of loss submitted?      
  If Yes Was it notarized? 
Claimant Information
Note: Or person being reported if different from insured.
Last Name or Business Name:  
First Name:  
Middle Name:  

Mailing Address:  
City:  
State:
ZIP Code: 
Line of Business/ Coverage Information
Note: 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
Note: 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?
Note: 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?
Note: If yes, select all that apply
   Insurance Company SIU    NICB Other State Fraud Unit
  Other Law Enforcement Agency  ( Please Identify )