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.
1. What is the name of the company or person you are reporting?
2. Do you know the address and telephone number?
3. If you are reporting a person, do you know the social security number, driver's license number, date of birth or approximate age?
4. Do you know the person's employer's name and address?
5. Do you know if the person uses any other names or an alias?
6. What other people are involved and what information do you have about them? [MAXIMUM 1000 CHARACTERS]
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7. What kind of insurance is it? (Ex. Worker's Compensation, Auto Liability, Health Insurance, Medicaid, etc.)
8. Do you know when the incident occurred? (This may be a specific date or approximate calendar time period, or it may be how long the suspected fraud has been going on.)
9. Why do you think this may be a fraudulent claim?
10. Describe what has happened: [MAXIMUM 1000 CHARACTERS]
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11. Do you have any documents that would help to prove that this claim is fraudulent?
12. Let us know any additional information that may be helpful: [MAXIMUM 1000 CHARACTERS]
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13. You may remain anonymous, but if you wish to leave your name and daytime phone number, please do so.