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Run: Suspected Insurance Fraud Reporting Form to State Fraud Bureau

This suspected insurance fraud reporting form organizes the minimum necessary case details, evidence, and referral status for submission to a state fraud bur...

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Submission Notice

Submission purpose

Acknowledgement of disclosure and use (required)

Yes No N/A

Internal submitter contact email (required)

Used for follow-up questions and audit trail. Do not enter external claimant or witness contact information here.

Case Identification

Claim number (required)

Policy number

Line of business (required)

State / jurisdiction (required)

Date suspected fraud was identified (required)

Suspected Fraud Details

Primary suspected fraud type (required)

Summary of suspected fraud (required)

Describe what happened, who is involved, and why the matter is being referred. Include observable facts, not conclusions.

Observed fraud indicators (required)

Date of loss

Loss location

Enter the location if it is relevant to the suspected fraud and already known.

Involved Parties

Is the insured or claimant involved in the suspected fraud? (required)

Involved party roles (required)

Names of involved parties

List only names needed for the referral. If a name is unknown, note the role and any identifying details you already have.

Is contact information available for any involved party? (required)

Contact information summary

Provide only the contact details needed for the referral package. Do not include sensitive identifiers unless required by law or agency request.

Evidence and Documentation

Evidence available (required)

Evidence summary (required)

Summarize what each item shows and how it supports the suspected fraud referral.

Upload supporting files

Upload only files needed for the referral package. Redact unnecessary PII where possible.

Audit trail notes

Record key dates, who reviewed the matter, and any prior internal escalation steps.

Referral and Review

Referral destination (required)

Current referral status (required)

Reason approval is required

Briefly note any legal, compliance, or management review required before external submission.

Attestation (required)

Yes No N/A

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