Insurance Claim Fraud Investigation Request Form
Submit details regarding a suspected fraudulent insurance claim for review by the investigation team.
Requester/Investigator Full Name
*
First Name
Last Name
Requester Email Address
*
example@example.com
Requester Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Insurer/Company or Department Name
*
Claim Reference Number
*
Policy Number
*
Claimant Name
*
Insured Person or Entity Name
Type of Insurance Claim
*
Please Select
Auto
Homeowners
Health
Life
Travel
Commercial
Other
Claim Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Incident or Loss Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Incident Location
Briefly describe why fraud is suspected
*
Known Parties Involved (if any)
Upload any supporting evidence or documents
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Urgency or Requested Action
*
Routine review
Expedited investigation requested
Immediate action required
Other
Additional Notes or Comments
Submit Investigation Request
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