I wish to remain Anonymous Citizen Insurance Professional Insurer
Law Enforcement SIU Member State/Federal Agency  
Please provide a brief summary of the facts of this matter:
Reporting Individual Information
Last Name:
First Name:
Middle Name:

Office Telephone: - -
Fax Telephone: - -
E-Mail Address:

Mailing Address:
City:
State:
ZIP Code:
Policy Information
Policy Number:
Name of Insurance Carrier:

Office Telephone: - -
Fax Telephone: - -
E-Mail Address:

Mailing Address:
City:
State:
ZIP Code:
Insured Information
Last Name or Business Name:
First Name:
Middle Name:

Mailing Address:
City:
State:
ZIP Code:
Claim Information
Claim Number:
Date of Claim:       

Total Approximate Claim Amount: $

Have any payments been made on this claim? Yes    No
If Yes Total Amount Paid: $

Amount of Unpaid Claim Suspected
   to be fraudulent: $
 Amount of Paid Claim Suspected
   to be fraudulent: $

Is claim still active? Yes    No
If No was claim denied?: Yes    No

Was claim withdrawn by claimant?    Yes   No
 If Yes Explain Briefly:

Was a written claim filed?   Yes    No
If Yes was it:    Mailed   Submitted in Person

Was the claim filed by telephone?    Yes   No
If Yes Was it recorded?   Yes No

Were any forms or payments on this claim sent through the mail?   Yes    No

Was a proof of loss submitted?       Yes    No
  If Yes Was it notarized?  Yes No
Claimant Information
Note: Or person being reported if different from insured.
Last Name or Business Name:  
First Name:  
Middle Name:  

Mailing Address:  
City:  
State:
ZIP Code: 
Line of Business/ Coverage Information
Note: Select all that apply
Property Fraud
Motor Vehicle/ Auto Homeowners Commercial Other
    Property Damage     Property Damage     Property Damage
    Stolen Vehicle     Theft/Loss     Theft/Loss
    Other (Explain)      Other (Explain)      Other (Explain) 
Bodily Injury/Casualty
Motor Vehicle/ Auto Homeowners Commercial Workers Comp
    Medical Payments     Personal Injury     Personal Injury Other
    Other (Explain)      Other (Explain)      Other (Explain) 
Describe the Nature of Suspected Fraudulent Activity
Note: Select all that apply
   Faked/ Exaggerated Property Damage   Inflated Financial Loss   Staged Accident/Injury
   Faked/ Exaggerated Injury   Previous Fraudulent Claims   Organized/ Ring Activity
   Suspected Arson   Faked/ Exaggerated Property Theft or Loss
  Other (Explain) 
        
What information has been developed to confirm your suspicion?
Note: Select all that apply
   Witnesses Photographs Videos Multiple Claims for Same Loss
   Investigative Reports Medical Reports Audio Tapes Correspondence
   Conflicting
        Statements
Depositions/
      Sworn Testimony
Falsified
      Documents
Claimant Lied Under Oath
  Other (Explain) 
        
Has this incident been reported to any other agency/organization? Yes    No
Note: If yes, select all that apply
   Insurance Company SIU    NICB Other State Fraud Unit
  Other Law Enforcement Agency  ( Please Identify )