Report Suspected Insurance Fraud

Your Name

First

Last

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Your Primary Phone Number

Additional Phone Number (Optional)

Email address

Description

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

Identify the parties to the suspect transaction (name/address and relation to the transaction). Add a second party below if needed.

Subject 1 Name

First

Last

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Party 1 Phone Number

Occupation

Place of Employment

Additional Information

Name of Insurance Company/HMO (If Applicable)

Subject 2 Name

First

Last

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Party 2 Phone Number

Party 2 Occupation

Party 2 Place of Employment

Name of Insurance Company/HMO (If Applicable)

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

Name of Agency

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

First

Last

Agency Phone Number

Attachment

One file only.
10 MB limit.
Allowed types: jpg, pdf, doc, docx.

Report Suspected Insurance Fraud

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