Online Form

Fraud Referral Form

Reporting Person (Select one)

I wish to remain Anonymous Citizen Insurance Professional Insurer Law Enforcement SIU Member State/Federal Agency

Reporting Person's Name (Type Answer)

(100 character limit; 100 remaining.)

Insurance Carrier / Agency (Type Answer)

(100 character limit; 100 remaining.)

Mailing address

Address Line 1:
Address Line 2:
City / State / Zip:

Phone number (Example: 999-111-0000)

Ext:

E-mail (Type Answer)

(100 character limit; 100 remaining.)

Insured's Information

Name or Business Name (Type Answer)

(100 character limit; 100 remaining.)

Street Address (include P.O. Box and apartment #'s)

Address Line 1:
Address Line 2:
City / State / Zip:

Telephone Number - Home (Example: 999-111-0000)

10.

Date of Birth (Type Answer)

(100 character limit; 100 remaining.)

11.

Sex (Select one)

Male Female

12.

Vehicle Information (Type Answer)

(100 character limit; 100 remaining.)

13.

Vehicle License Plate # (Type Answer)

(100 character limit; 100 remaining.)

Claimant/Suspect Information (if different then Insured)

14.

C/S Name (Type Answer)

(100 character limit; 100 remaining.)

15.

C/S Street Address (include P.O. Box and apartment #'s)

Address Line 1:
Address Line 2:
City / State / Zip:

16.

C/S Address Type (Select one)

Residence Business Maildrop Other State Fraud Bureau

17.

C/S Telephone Number - Home (Example: 999-111-0000)

18.

C/S Date of Birth (Type Answer)

(100 character limit; 100 remaining.)

19.

C/S Sex (Select one)

Male Female

20.

C/S Vehicle Information (Type Answer)

(100 character limit; 100 remaining.)

Claim Information

21.

Date of Claim (Type Answer)

(100 character limit; 100 remaining.)

22.

Claim # (Type Answer)

(100 character limit; 100 remaining.)

23.

Claim Amount $ (Type Answer)

(100 character limit; 100 remaining.)

24.

Type of Claim (Select one)

Auto W/C Homeowners LAH General Liability Other

Information About Fraud

25.

Describe Suspected Criminal Activity (Type Answer)

(500 character limit; 500 remaining.)

Reason for New Hampshire Jurisdiction

26.

Reason for New Hampshire Jurisdiction (Select one)

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

Identify Other People Who May Have Information

27.

Name of Person (Type Answer)

(100 character limit; 100 remaining.)

28.

Address of Person

Address Line 1:
Address Line 2:
City / State / Zip:

29.

Telephone Number of Person (Example: 999-111-0000)

Identify Other Agencies You Have Contacted Regarding This Matter

30.

Identify Other Agencies You Have Contacted Regarding This Matter (Select one)

Other State Fraud Bureau Law Enforcement Other Insurance Company Regulatory Agency NICB Other