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Insurance Fraud Investigation Report

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 seek Insurance's assistance, please mail the Fraud Investigation Report (Insurer) (PDF, 73K) and follow the instructions on page 2.

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:
Social Security Number:
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 (specify):

*Details of Complaint

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Insurance Fraud Investigation Report

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