Complaints_main_banner

Insurance Fraud Industry Complaint Form

Please Note: As part of the complaint handling process, the Bureau may send a copy of this form to the individual or company against whom your complaint is filed. Failure to supply your complete and accurate contact information may result in delayed processing of your complaint.

*indicates required field

Referred by

Your Name*

Company Name*

Address*

City*

State*

County

Zip Code*

Phone Number*

Fax Number*

Email*

 

Subject Information

Include additional subjects in the Fraud Allegation/Summary Section

Name (include any known Alias)*

Address

City

State

County

Zip Code

Phone Number

Home Phone Number

Email

Date of Birth

SSN (XXX-XX-XXXX)

Address Type

   

Sex

   
 

Referral Status?

Have you referred this to any other law enforcement agency?

   

If yes, identify

Agency

Contact Person

  

Reason why you are sending this matter to our office

   
 

Location Information - City, County, State

Incident occurred In

Insurer payment sent from

Claim was received in

Payment was sent to subject at

False statement made

 

Claim Information

If additional companies are involved please include in the Fraud Allegation/Summary Section

Policy Number

Claim Number

Policy Limits $

Date of Loss

Date Claim Made

Amount Claimed

Amount Paid

Status of claim

   

If other, please state

 

Type of Insurance/Fraud Involved

If other, please state

 

 

Fraud Allegation / Summary

Fraud Summary*