Fraud Claim Adjudication Form

Fraud Claim Adjudication Form
Submit, assess, and adjudicate reported fraud claims with all necessary details and documentation.
Claimant Full Name
First NameLast Name
Claimant Email Address
example@example.com
Claimant Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Claim Reference Number
Date of Incident
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Location of Incident (Address)
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Description of the Alleged Fraudulent Activity
Upload Supporting Evidence (photos, documents, etc.)
Cancelof
Assessment of Claim Details
Rows Clarity of Evidence Provided Consistency of Claim Likelihood of Fraud
Low
Medium
High
Adjudicator's Decision
Adjudicator's Comments / Rationale for Decision
Adjudicator's Signature
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Rows	Clarity of Evidence Provided	Consistency of Claim	Likelihood of Fraud
Low
Medium
High