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Insurance Fraud Private Citizen 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


Your Information


 

Your Name

Address

City

State

County

Zip Code

Daytime Phone Number

Home Phone Number

Email

 

Subject Information

Include additional subjects in the Fraud Allegation/Summary Section

Name*

Address

City

State

County

Zip Code

Daytime Phone Number

Home Phone Number

Email

Date of Birth

SSN (XXX-XX-XXXX)

Address Type

    

Sex

    
 

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*