Private Citizen Insurance Fraud Complaints

Suspect someone is committing insurance fraud? Private citizens can use this form to report it to our Insurance Fraud Section. Describe what you’ve observed and provide any supporting details so our investigators can review the matter.

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Your Information

Your Name*

First Last

Address

Street Address City State Zip Code

County

Best Phone Number*

Alternative Phone Number (Optional)

Email*

Suspect Information

Include additional suspects in the Fraud Allegation/Summary Section

Name*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Address Type

Residential

Business

Other

Sex

Male

Female

Daytime Phone Number

Home Phone Number

Date of Birth

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Social Security Number

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*

Fraud Summary

Complaint Form Uploads

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Max. file size: 256 MB, Max. files: 25.

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Private Citizen Insurance Fraud Complaints

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Your Information

Suspect Information

Claim Information