Pennsylvania Office of Attorney General

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

Subject Information
(if additional subjects, please include in the Fraud Allegation/Summary section)

Referral Status


Location - City, County (if known), State
Do not put dates in this section

Claim Information
(If additional Companies are involved please include in Fraud Allegation/Summary Section)

Fraud Allegation/Summary
(this section must be completed)

Before submitting this form to the Office of Attorney General, please print out this page for your records