Report Suspected Fraud
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A confirmation number will be provided upon submission.
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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