Fraud Investigation Report Form

Note: This form is for insurers who seek only to report a claim or other activity believed to be fraudulent. Do not send any additional documentation.

If you are a policyholder or claimant and you are having a problem with an insurance company, agent, broker, agency or producer, please use our consumer complaint form.

Fields marked with an asterisk [*] are required.

*Company Information (all fields required)

Company Name:
Company Representative:		Position:
E-mail Address:
Phone Number:
Mailing Address:
City:		State:		ZIP Code:

Insured Information

*Insured
Employer name (if group policy)
*Mailing Address
*City		*State		*ZIP Code

Who is complaint against? (name of consumer, insurance producer, etc)

*Name
Date of Birth:
Address (if known):
City:		State:		ZIP Code:

Claim Information

Group or Certificate Number:
Policy or ID Number:
Effective Date:
Claim Number:
Producer Name (if applicable):
Date of Loss:

*Nature of Complaint (Must have at least one)

Life Group Health Individual Health Auto Liability Fire Homeowners
Workers Compensation Other, please specify:

*Details of Complaint