Create - CDI Information Form

CDI Submission Details Form
Use this screen to enter suspected fraudulent claim or insurance transaction information.

California Insurance Code (CIC) Section 1872.4 requires companies licensed to write insurance in California to submit this form WTHIN 60 DAYS after determining that a claim appears to be fraudulent. CIC Section 1877.3 further requires reporting of suspected fraudulent Workers' Compensation claims to BOTH the CDI Fraud Division and the local District Attorney's Office WITHIN 60 DAYS

Warning! There is a 90-minute time limit to enter the information below.

Completed By: This is the person who completes the form.

Full Name

Phone

File Handler: This is the person who handles claim documents.

Full Name

Phone

Reporting Party:

Please be advised that users will need to enter an accurate NAIC number for compliance and reporting accuracy. If there is no available NAIC number, you will need to use CDI’s eFD-1 company portal to submit the fraudulent referral.

NAIC Number

Invalid NAIC number

Company Name

Address

Street

City

State

Zip Code

Contact

First Name

Last Name

Title

Phone

Alleged Victim:

NAIC Number

Invalid NAIC number

Company Name

Fraud Type:

Fraud Type Group

Fraud Type

Loss Information:
California Insurance Code (CIC) Section 1872.4 requires companies licensed to write insurance in California to submit this form WTHIN 60 DAYS after determining that a claim appears to be fraudulent. CIC Section 1877.3 further requires reporting of suspected fraudulent Workers' Compensation claims to BOTH the CDI Fraud Division and the local District Attorney's Office WITHIN 60 DAYS

Warning! Claim number or policy number is required

Policy Number

Claim Number

Loss Date

Loss Address

Street

City

State

Zip Code

Note: If the loss occurred outside California, enter a California ZIP code that can relate in the closest manner to the loss location.

California Zip Code

Loss Amounts

Actual Paid To Date Amount

Suspected Fraudulent Loss To Date Amount

Potential Loss Amount

Premium Loss Amount

Suspected Fraudulent Claim Summary:
Please provide a complete summary of all the facts on which the reasonable belief of insurance fraud is based, that has been prepared pursuant to California Code of Regulations, Section 2698.36(a)(5). If known, the summary shall include the following information, required by California Code of Regulations, Section 2698.38(d((9). (Effective October 1, 2020) *California Insurance Code

What facts caused the reporting party to believe insurance fraud occurred or may have occurred?

What are the suspected misrepresentations and who it was that allegedly made them?

How is the alleged misrepresentation(s) material, how do they affect the claim or transaction?

Who are the pertinent witnesses to the alleged misrepresentation and what documentation exists?

Include a statement as to whether or not the investigation is complete.

Note: For additional information specific to the five questions listed above (related to specific insurance lines), click on the applicable link below. Responding to the additional information requested in the links is strictly voluntary. Failure to include this additional information with your referral shall not form the basis of a declination to pursue an investigation pursuant to the California Insurance Code.

DISASTER CLAIMS: If this suspicious activity is related to a major natural or non-natural disaster, select the option below that best describes the related event:

Report To Other Agencies:

Required for California Workers' comp referrals

District Attorney Office

Other Enforcement Agency

Other Agency

Party Listing:

*Click Edit to review details and select Party Type Code

Warning! Type "15 - Employer" is required for Workers Compensation claim. Type "00 - Insured" is required for any other claims.

Party Type Code	First Name	Last Name	Company Name	Birth Date	SSN	Tax ID	DBA Name	Action
Alert! No PTTLs have been added.

Add

Effective May 4, 2021: Referrals submitted through ISO/NICB will be submitted directly to the CDI Fraud Division for processing. Users are no longer required to log into the eFD-1 company portal to add additional information if they have already submitted and completed the California portion in ISO/NICB.

CDI Submission Details Form Use this screen to enter suspected fraudulent claim or insurance transaction information.

Completed By: This is the person who completes the form.

File Handler: This is the person who handles claim documents.

Reporting Party:

Alleged Victim:

Fraud Type:

Report To Other Agencies:

Party Listing:

CDI Submission Details Form
Use this screen to enter suspected fraudulent claim or insurance transaction information.