Insurance Fraud Referral Form
Commonwealth of Pennsylvania
Office of Attorney General
Please Note:
This form is intended for use by Private Citizens.
Referred By
Check here if referring anonymously and continue to Subject Information
Your Name:
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)
Claim Information
(If additional Companies are involved please include in Fraud Allegation/Summary Section)
Insurance Company:
Claim Number:
Policy Number:
Date of Loss:
Date Claim Made:
Amount Paid:
Fraud Allegation/Summary
(this section
must
be completed)
Fraud Summary:
Before submitting this form to the Office of Attorney General, please print out this page for your records