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Fraud Referral Form

Insurers can use this form as a stand-alone referral
 
Reporting Person
I wish to remain Anonymous  Citizen  Insurance Professional  Insurer  Law Enforcement
SIU Member  State/Federal Agency
Reporting Person's Name
Insurance Carrier / Agency
Mailing address
Phone number (Example: 999-111-0000)
Fax number (Example: 999-111-0000)
E-mail
NAIC CoCode (MANDATORY)
Insured's Information
Last Name or Business Name
First Name
Middle Name
Street Address (include P.O. Box and apartment #'s)
Address Type Residence  Business  Maildrop  Other
Telephone Number Home   Cell   Business
Date of Birth
Approximate Age if DOB is unknown
SS# (type in at your own risk - this is NOT a secure site
Sex Male  Female
Driver's License # (type in at your own risk - this is NOT a secure site
State where license is issued from
Vehicle
Year   Make   Model   License Plate #   VIN #
Employer
Employer Address and Telephone Number
Occupation
Federal TIN
EIN
Claimant/Suspect Information (if different then Insured)
C/S Last Name or Business Name
C/S First Name
C/S Middle Name
C/S Street Address (include P.O. Box and apartment #'s)
C/S Address Type Residence   Business   Maildrop   Other State Fraud Bureau
C/S Telephone Number Home   Cell   Business
C/S Date of Birth
C/S Approximate Age if DOB is unknown
C/S SS# (type in at your own risk - this is NOT a secure site
C/S Sex Male  Female
C/S Driver's License # (type in at your own risk - this is NOT a secure site
C/S State where licenses is issued from
C/S Vehicle
Year   Make   Model
License Plate #   VIN #
C/S Employer
C/S Employer Address and Telephone Number
C/S Occupation
C/S Federal TIN
Claim Information
Claim Information Paid  Denied  Pending  Withdrawal  Other
Date of Claim (Example: MM/DD/YYYY)
Claim #
Policy #
Claim Amount
Deductible Amount
Type of Claim
Auto  W/C  Homeowners  LAH  General Liability  Other
Information on False Statement/Criminal Activity
Describe False Statement/Information Concealed or Other Suspected Criminal Activity
Evidence That Claimant/Suspect Acted Knowingly and/or With Intent
Evidence That Claimant/Suspect Acted Knowingly and/or With Intent to Defraud/Deceive the Insurer
Admission  Misrepresentations  Financial motive  Failed to avoid harmful consequences  Failed to pursue claim/withdrew claim  Obstruction of investigation  Other motive  Other
Evidence Demonstrating Identity of Claimant/Suspect
Eyewitness Insurance agent  SIU  Law enforcement  Stranger  Friend/Family
Other
Admission To Insurance agent  To SIU  To Law enforcement  To Stranger  To Friend/Family  To Other
By Telephone  In-person
Signature Comparison Comparison to driver's license  Comparison to other known sample  Identification by person familiar with handwriting  To Other
Check deposited into Insured/Claimant's bank account Yes  No
Check cashed by Insured/Claimant Yes  No
Computer forensics Yes  No
Fingerprints/DNA Yes  No
Other
Reason for New Hampshire Jurisdiction
Reason for New Hampshire Jurisdiction
False statement made/prepared in NH  False statement placed into mail in NH  False statement faxed from NH  Payment received in NH  Money misappropriated in NH  False statement received by insurer in NH  Other
Has Suspect Provided a Statement?
Yes Admission  Denial  Other
No Refused  Expected to take place in future  Not requested
Other
Identify Other People Who May Have Information
Name of Person 1
Address of Person 1
Telephone Number of Person 1
Name of Person 2
Address of Person 2
Telephone Number of Person 2
Identify Other Agencies You Have Contacted Regarding This Matter
Identify Other Agencies You Have Contacted Regarding This Matter Other State Fraud Bureau  Law Enforcement  Other Insurance Company  Regulatory Agency  NICB  Other
Agency Name and Contact Person
Other
Civil Litigation or Administrative Proceedings Pending Yes  No
Agency/Court
Is there any reason to believe that this incident is related to other suspected fraudulent activity? Yes  No
Insurer's Attorney on this Matter Yes (Name, Address and Phone Number of Insurer's Attorney) No
Claimant's Attorney on this matter Yes (Name, Address and Phone Number of Insurer's Attorney) No
 

Fraud Unit
New Hampshire Insurance Department
21 S. Fruit St., Ste 14
Concord, NH 03301
603-271-7973
www.nh.gov/insurance/legal/fraud/
NHFraud@ins.nh.gov

NH RSA 417:28 provides that "Any company which believes that an insurance fraud has been committed shall, within 60 days of forming such belief, send to the unit, on a form prescribed by the unit, the information requested and such additional information relative to the claim and other parties claiming loss or damage because of the claim as the unit may require.In the absence of fraud or malice, no public official or insurance company or person who furnishes information on behalf of the insurance company shall be liable for damages in a civil action or subject to criminal prosecution for any oral or written statement made or any other action taken that is necessary to supply information required pursuant to this section."
 
    New Hampshire Insurance Department | 21 South Fruit Street, Suite 14 | Concord, NH 03301
Phone 603.271.2261 | Fax 603.271.1406 | Consumer Hotline 1.800.852.3416
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