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Louisiana Department of Insurance -- FRAUD Section
Louisiana State Police -- Insurance FRAUD/AUTO THEFT Unit

Confidential Suspected Fraudulent Claim Report

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A red asterisk(*) Denotes a required field.


* Submitted For:
Section 1 of 9

Submitter Information
* First Name:
Middle Name:
* Last Name:
* Work Phone:
Cell Phone:
Home Phone:
* Address Line 1:
Address Line 2:
* City:
* State and Zip:
NAIC:
* Company:
* Email:

Insured Information (Affected Policy)
First Name:
Middle Name:
Last Name:
Work Phone:
Cell Phone:
Home Phone:
Address 1:
Address 2:
City:
State and Zip:
Email:
Section 2 of 9

* Person Suspected:
How many suspects are being reported?

Section 3 of 9

Claim Information
Claim Number:
Effective Date:
Date Reported to the Company:
Policy Number:
Date Of Loss:
Time of Loss:
Section 4 of 9

Type of Insurance (Please check all that apply)
Property & Casualty









Life






Health & Annuities









Misc





Section 5 of 9

Type of Fraud (Please check all that apply)








































Other:
* Total Claim Amount: Has any of this claim been paid
Section 6 of 9

Are there referrals to any other entities, (i.e. Law Enforcement Agencies, Professional Boards, etc.)?
*
Section 7 of 9

Name(s) of individuals significant to loss (include doctors, lawyers, witnesses, etc.)
How many individuals are you reporting?
Section 8 of 9

* Detailed Facts of Suspected Fraudulent Conduct:


Section 9 of 9

Attachments
Do you have documentation to support this submission?
*  

Thank you for your 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 information.



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