Name: __________________________________________________________________________

Address: ________________________________________________________________________

_______________________________________________________

_______________________________________________________

Telephone No.    Home ______________   Business _________________

1) Give a brief statement of the suspect transaction and the amount of money involved (if known):

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

2) Identify the parties to the suspect transaction (name/address and relation to the transaction):

(Use additional forms for multiple suspects)

Name:  ______________________________________________________

Address: _____________________________________________________

Telephone No.  Home: ________________ Business: _______________

Occupation:__________________________________________________

Where Employed: ____________________________________________

Additional Information:

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

3) Name and address of insurance company/HMO (if applicable):

_______________________________________________________

_______________________________________________________

4) Have you reported this transaction to any other law enforcement agency? If yes, please furnish the following information:

Name of Agency: _______________________________________________

Address: _______________________________________________________

Person Contacted: ___________________ Phone # ___________________

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To send by mail:

State of New York
Department of Financial Services
Insurance Frauds Bureau
Room 542
25 Beaver Street
New York, NY 10004

To send by fax: (212) 480-7148

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