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Louisiana Department of Insurance -- Fraud Section
Louisiana State Police -- Insurance Fraud Unit

Confidential Suspected Fraudulent Claim Report

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Section 1 of 9

Company
NAIC
Contact Person
Phone
Address
Insured(s) Name
Phone
Address

 

Section 2 of 9

(Please use additional forms for each person suspected of commiting a fraudulent act)

Person Suspected Phone
       
Address
Employer Phone
       
Occupation DOB
       
Driver's License State
       
Social Security #

Section 3 of 9

Claim Number
Date Reported
Date of Loss
           
Policy Number
Effective Date
Time of Loss
   
Location / Detail of Loss

Section 4 of 9

Type of Fraud

(Please check all that apply)

  Agent Theft   False Application Jump-in Medical
                   
  False Billing Repair Fraud Slip and Fall Health Care
                   
  Worker's Compensation Kickback Phony Theft Provider
                   
  Premium Avoidance False/ Exaggerated Loss Statement
           
Staged Accident  
      Other (Please Explain)
  Money Laundering

Section 5 of 9

Type of Insurance
Has this claim been paid
 Yes No
Claim Amount

Section 6 of 9

Referral to any other entities, (i.e. Law Enforcement Agencies, Professional Boards, etc.)

Name of Entity
Date of Referral
       
Contact Person
Phone:

Section 7 of 9

Name(s) of individuals significant to loss (include doctors, lawyers, witnesses, etc.)

Phone
Phone
Phone

Section 8 of 9

Brief Description of Facts (please forward copies of any supporting documents)

 
 
 
 

Section 9 of 9

Name of Authorized Representative Date