Consumer Insurance Fraud Reporting Form

Section 1 - Consumer, Agent or Business Reporting Fraud

Are you filing as a private individual, Licensed Agent, or on behalf of a Business?

I wish to file Anonymously

NoYes

Click checkbox if you don't want to disclose info

Agent License Number

Last Name

Phone Number

First Name

Company Name

Street Address

City

State

Zip Code

Are you a victim of the alleged violation/fraud?

NoYes

Victim Information

Last Name

First Name

Address

Business Name

City

Phone Number

State

Zip Code

Section 2 - Person or Business Committing Fraud

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Error completing request.

Where did the fraud occur?

City

Zip

Is this fraud still occurring?

NoYes

Date of Fraud or When did you get suspicious

Policy Number (optional)

Section 3 - Insurance Fraud Details

Please describe what fraudulent activity you wish to report

Who are the persons committing the fraud?

When and where did the fraud occur?

What is the name of the insured if different than the suspect?

Include names of others who can corroborate this information

Is anyone in the insurance industry aware of what is occurring?

Section 4 - Other Referrals

If an insurance company has been notified of this activity, please identify the company

Other Law Enforcement Agency

District Attorney Office

If another agency has been notified of this activity, please identify the agency

Consumer Insurance Fraud Reporting Form

Consumer Fraud Reporting Portal

Section 1 - Consumer, Agent or Business Reporting Fraud

Section 2 - Person or Business Committing Fraud

Section 3 - Insurance Fraud Details

Section 4 - Other Referrals