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Phone Type: *

Case Details
SIU Investigation Complete

Civil Litigation Pending
 


Information about the Individual/Business Suspected Committing Fraud

*        Is this an:    *

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    Phone Type:
 
 


Claim/Incident Information


Insurance Type*





Claim Denied?




 
Location of Loss
*

Law Enforcement Agency Information

Is any LAW ENFORCEMENT AGENCY involved? If No, skip to the next section

 

Suspected Fraud Type

Please select one or more that apply *


  Application/Eligibility fraud Arson
          













  Fictitious theft
       



  Inflated theft
       





























Information on Additional Individual/Business

:        Is this an:       


    Phone Type:    
 

Reason for Referral

such as *
    What happened?
    How did you find out about it?
    Why do you think it is insurance fraud?


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