Louisiana Department of Insurance Fraud Hotline

When you complete your answers to the questions, select the "Submit" button. This will create a confidential record in our FRAUD Database.

The following questions regard information that is helpful to us in pursuing such tips. The Suspected Fraudulent Claim Report must be used by companies. Individuals are welcome to use it as well if it fits their needs. Please enter your comments in the spaces provided below. Thank you for your help and cooperation.

Problems using this form? If so, click here to report them. Please be as descriptive as possible.

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Suspect's Information

Are you reporting an individual or a business? (Required)

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Type of Insurance

Please indicate the type(s) of insurance. You may select more than one.

Property and Casualty 301 - P&C-Auto-Personal308 - P&C-Auto-Motorcycle 302 - P&C-Auto-Commercial/Business309 - P&C-Auto-Warranty 304 - P&C-Auto-Uninsured Motorist310 - P&C-Auto-Gap Coverage 305 - P&C-Auto-Motor Home/RV390 - P&C-Auto-OTHER… 307 - P&C-Auto-Driver Exclusion 401 - P&C-Commercial-Fire/Industrial406 - P&C-Commercial-Crime 402 - P&C-Commercial-Liability407 - Comm-Business 403 - Comm-Credit Property408 - P&C-Commercial-Property 405 - P&C-Commercial-Business Owner's490 - P&C-Commercial-OTHER… 501 - P&C-Homeowners-General504 - P&C-Homeowners-Flood 502 - P&C-Homeowners-Mobile Home590 - P&C-Homeowners-OTHER… 503 - P&C-Homeowners-Renters Life 601 - LIFE-Individual608 - Life-Variable Life 602 - LIFE-Group609 - Life-AD&D 603 - LIFE-Annuity610 - Life-Burial 604 - Life-Credit611 - LIFE-Viatical Settlement 605 - LIFE-Industrial614 - Life-Long Term Care 606 - LIFE-Accelerated Benefits690 - LIFE-OTHER… 607 - Life-Variable Annuity Health and Annuity 701 - A&H-Major Medical-Individual711 - A&H-Dental 702 - A&H-Major Medical-Group712 - A&H-Hospital Indemnity 703 - A&H-Medicare Supplemental713 - A&H-Accident Only 704 - A&H-Disability716 - Medicaid 705 - A&H-Credit717 - Medicare 706 - A&H-Long Term Care722 - Prescription Drug 707 - A&H-Cancer724 - Vision 708 - A&H-HMO790 - A&H-OTHER… 709 - A&H-Mult Empl Welfare Arrang-MEWA799 - A&H-Major Medical-Industrial 710 - A&H-Single Empl Trust-ERISA Misc 801 - P&C-Liability-General805 - Liab-Excess 802 - P&C-Liability-Errors & Omissions806 - Liab-Business 803 - P&C-Liability-Umbrella890 - P&C-Liability-OTHER… 901 - MISC-Worker's Compensation905 - Misc-Title 902 - MISC-Fidelity-Surety/Bond990 - MISC-OTHER… 903 - P&C-Marine-Ocean999 - P&C-Surplus Lines 904 - P&C-Marine-Inland

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Fraudulent Activity

Occurrence Date, if known:	Open the calendar popup. << < February 2012 > >>   S M T W T F S 5 29 30 31 1 2 3 4 6 5 6 7 8 9 10 11 7 12 13 14 15 16 17 18 8 19 20 21 22 23 24 25 9 26 27 28 29 1 2 3 10 4 5 6 7 8 9 10
Detailed Facts of Suspected Fraudulent Conduct:

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Attachments

Will you include any documentation to support this submission? YesNo

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Submitter Information

You may remain anonymous, but if you would like to leave your contact information, please do so.

First Name: Last Name: Cell Number: Home Number: E-mail Address:

Address Line 1: Address Line 2: City: State and Zip: AK AL AR AZ CA CN CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY

Should the Louisiana Department of Insurance FRAUD Section determine that the allegations in this Suspected Fraud Report do not constitute insurance fraud, does the FRAUD Section have your permission to refer the complaint to the appropriate government entity for further consideration? (Required) YesNo
Please note that by checking “Yes” you understand that this complaint will not remain confidential if referred to another government entity.

Thank you for this submission. Louisiana law provides that, upon receipt by the FRAUD Section, the Suspected Fraud Report is confidential and no status report can be given. The FRAUD Section may, however, contact you for additional facts if you provide your contact information.