Insurance Fraud Referral Form
Commonwealth of Pennsylvania
Office of Attorney General
Please Note:
This form is intended for use by the Insurance Industry.
Referred By
Name (Contact Person):
Company:
Address 1:
Address 2:
City:
State:
Zip:
Telephone: (###-###-#### format)
Fax: (###-###-#### format)
Email address:
Subject Information
(if additional subjects, please include in the Fraud Allegation/Summary section)
Name (include any known Alias):
DOB: (MM/DD/YYYY)
SSN:
(xxx-xx-xxxx)
Address 1:
Address 2:
City:
State:
Zip:
Address Type:
Residential
Business
Other
Sex:
Male
Female
Telephone: (###-###-#### format)
Referral Status
Have you referred this matter to any other law enforcement agency?
Yes
No
If Yes, identify:
Agency:
Contact Person:
Reason why you are sending this matter to our office:
Requesting an investigation
For informational purposes only
Location - City, County (if known), State
Do not put dates in this section
Incident Occurred In:
Payment Was Sent by Insurer From:
Claim was Received In:
Payment Was Sent to Subject at:
False Statement Made:
Claim Information
(If additional Companies are involved please include in Fraud Allegation/Summary Section)
Policy Number:
Claim Number:
Policy Limits: $
Date of Loss:
Date Claim Made:
Amount Claimed: $
Amount Paid: $
Status of Claim:
Paid
Denied
Withdrawn
Pending
Settled
Other:
Type of Insurance/Fraud Involved:
Auto
Rate Evasion
Homeowners / Renters
Commercial
Health
Disability
Life
Workers Compensation
Agent / Fraud Company
Other:
Fraud Allegation/Summary
(this section
must
be completed)
Fraud Summary: