Website Main Menu
 

 
Suspected Fraud Claim Form

Your Name:
Address:
City:   State:     Zip: 
Email:
Daytime Phone:
Evening Phone:
Discovery Date:
Describe nature of suspected fraudulent activity (Check all that apply)
Faked property damage Billed for services not provided
Inflated financial loss Billed for excessive or extended treatments
Faked/exaggerated Injury Fabricated services
Staged accident/injury Charges inconsistent with services provided
Been known to file suspect claims

Other:

Provided an inaccurate/incomplete history
Summary of Activities:
What information has been developed to confirm your suspicion? (Check all that apply)
Witnesses Correspondence
Photographs Falsified documents
Medical reports Multiple claims for same loss
Conflicting statements Depositions/sworn testimony
Videos Claimant lied under oath
Investigative Reports Other:
Information being developed:
Do you have any reason to believe this incident is related to other fraudulent activity?
Yes
If yes, please describe:
Have you reported this matter to other organizations? (Check all that apply)
County Attorney's Office (County ) NICB
U.S. Attorney's Office OTHER
Other Law Enforcement
Is this an insurance company referral?
Yes   Company: Claim#:
Contact:    Address:   Phone:
City:  State: Zip:
Suspect
Last: First: MI: Birth: SSN:
Street: City: State: Zip: Phone:
V.I.N.:
Driver's
License:
License   Plate:
State:
Prof
License: