Uniform Fraud Reporting Form
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2
3UNIFORM SUSPECTED INSURANCE FRAUD REPORTING FORM
For State Use Only
State of
Case No.
Division of Insurance – Fraud Bureau
Reporting Person Information
Name and Title:
Insurance Company:
NAIC#
Mailing address (include department):
Phone number: (
)
Fax number: (
)
E-mail address:
Case Details
SIU Investigation Completed:
Yes
No
Date Completed:
SIU Case #:
Civil Litigation Pending:
Yes
No
Is there any reason to believe that this incident is related to other suspected fraudulent activity?
Yes
No
Subject Information
Type:
Name (Last / Business):
(First):
(Middle):
Date of birth:
Age:
Sex:
M
F
Street Address (include P.O. Box and apartment #’s):
Driver’s License # & State:
SSN:
TIN:
NPI:
EIN:
City:
State:
Zip:
County:
Telephone No.:
Phone Type:
(
)
home
cell
bus.
Address Type:
E-Mail Address:
Telephone No.:
Phone Type:
(
)
home
cell
bus.
Res.
Bus.
Maildrop
Other
VIN:
License Plate # & State:
Vehicle Yr:
Make:
Model:
Employer:
Address & Phone #:
Occupation:
Additional Subject/Party Involved?
Reported Injuries:
Comments: (ex. other ID information and source)
AKA Information?
If checked, complete Page 3
Claim/Incident Information
(all financial information and dates of service are considered approximate)
Claim #
Policy #:
Insurance Company Case #:
Insurance Type
Property/Casualty
Disability
Work Comp
Auto
Health
Life
Unknown
Other
Potential Loss Amount $
Amount Paid $
Reserve Amount $
Claim Status
Date Paid
Unknown. Please estimate:
Billed Amount
Dates of Service:
to
$1 - $5,000
$
$5,001 - $25,000
Description of Service:
$25,001 - $75,000
Settlement Amount $
Procedure Code Type:
CPT
CDT
$75,001 +
Date Paid
Unable to estimate
Procedure Codes:
Date of Loss / Injury:
Address:
THIS SPACE IS INTENTIONALLY LEFT BLANK
City:
County:
State:
Zip:
Identify Another Agency You Have Contacted Regarding This Referral
Agency Type:
Other State Fraud Bureau
Law Enforcement
Other Insurance Co.
Regulatory/Gov’t Agency
Other
Agency:
Contact Person:
(Address)
(City)
(State)
(Zip)
Telephone (
)
Fax (
)
E-mail
Case/Claim No.
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