Fillable ADOI FRAUD REFERRAL 100 N. 15th Ave, #102 (Arizona)

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ADOI FRAUD REFERRAL 100 N. 15th Ave, #102 (Arizona)

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Form F101 Rev. 03/19
100 N. 15th Ave, #102
Phoenix, AZ 85007-2624
602-364-2140
FAX: 602-912-8419
SUBMITTED TO INITIATE INVESTIGATION SUBMITTED FOR INFORMATION ONLY
PLEASE REVIEW INSTRUCTIONS ON THE REVERSE SIDE OF THIS FORM
Date of Preparation Insurance Company Name NAIC
Insurance Company Address City State ZIP Code
Contact Person Name E-mail Address Phone Number
Policy Number Claim Number Date of Loss
Reason for Suspicion
Codes
Has law enforcement
received this information?
☐YES ☐NO IF YES, complete ►
Law Enforcement Agency
Law Enforcement Contact Person Phone Number
Why do you suspect fraud (reason for referral)?
Location of Loss: Address City State ZIP Code
Policy Type Loss Type Est. Claim Value
Was claim paid?
☐YES ☐NO
INFORMATION FOR WORKERS’ COMPENSATION OR HEALTH CARE PROVIDER REFERRAL (otherwise, leave blank)
Health Care Provider Tax ID Number Phone Number
Health Care Provider Address City State ZIP Code
Is the health care provider the subject of this referral?
☐YES ☐NO
Did the subject of this referral previously submit suspicious claims?
☐YES ☐NO
Has any outside investigation or surveillance been conducted?
☐YES ☐NO Video? ☐YES ☐NO
Outside Investigator Name E-mail Address Phone Number
CLAIMANT AND OTHER ROLE INFORMATION - Please provide additional role information using Form 100
#1
Role First Name Middle Name Last Name Jr/Sr/III/etc.
Name of Business, DBA or Alias Phone Number
Address City State ZIP Code
DOB SSN TIN(S)
Occupation Driver License # State
Vehicle ID Number (VIN) Year Make Model Style/Color
License Plate # Year State Type
Reported Injuries, Disease, Illness or Condition
ADOI
USE
ONLY
ADOI Reviewer Date Control Number
Case Assigned To Date Referral Disposition Code
ADOI
Arizona Department
of Insurance
FRAUD REFERRAL
Page ____ of ______
*
See Instructions on Reverse Side
PRINT
CLEAR FORM
INSTRUCTIONS
To expedite the referral process please fill
out all necessary items as completely as
possible.
Use a separate form for each claim number
and mail or fax to the address/phone listed
below.
Use as many forms as necessary for
additional insured, claimants, doctors,
attorneys, etc. And repeat the claim number
on every form.
Staple all related forms together.
M
AIL TO: ADOI - FRAUD UNIT
100 N. 15
TH
AVE., #102
P
HOENIX, AZ 85007-2624
FAX TO: 602-912-8419
R
EASON FOR SUSPICION CODES
Code Description
AM Application Misrepresentation
AR Arson
CI Claim Investigation Resulted
In Denial/Reduction/
Withdrawal
FL
Fictitious Loss
IF Inflated Loss
IS Illegal Solicitation (chasers/
Cappers)
KB Kick Backs/Bribery
MC Multiple Claims
ML Medical Provider/Lawyer
Relationship
MP Medical Provider
MS Misappropriated Vehicle
Salvage
QB Questionable Billing
RO Ring/Organized Activity
(excl. veh.)
RW Returned to Work
SA Staged/Caused Accident
SR Specials/Receipts (Altered/
Questionable/Duplicate)
UR Unperformed Repairs
VA Vehicle Arson
VF Vehicle
VR Vehicle Ring Activity
VT Vehicle Theft
WC Work Comp Claimant
WP Work Comp Premium
FE Fictitious Employee/
Dependent
FG
Forgery
DM Diversion/Misappropriation of Funds
OT Other
LICENSE TYPE CODES
Code Description
PC Passenger Car
TK Truck
TL Trailer
MC Motorcycle
CO Construction Equipment
BU Bus
FM Farm
IP International Plate
IT In Transit
TR Truck/Trailer
ZZ All Others (snowmobiles,
ATVs, etc.)
POLICY TYPE CODES
Code Description
PAUT Personal Automobile - General
PPAP Personal Property - General
PPHO Personal Property -Homeowners
COMP Commercial - Multi Peril
CCRM Commercial Crime
CAUT Commercial Automobile
CPRP Commercial Property
WORK Worker’s Compensation
ACHE Accident/Health/Disability
LIFE
Life
MAME Major
Medical
HHMO HMO
ACON Accident Only
PRDG Prescription Drug
DEVI Dental/Vision
HCMS
Health Care/Medicare Supp.
CASD Cancer/Specified Disease
MESH Medical/Surgical Hospital
OTHR Other
LOSS TYPE CODES
Code Description
BIAR Bodily Injury
Auto
Related
BISF Bodily Injury
Slip & Fall
BURG Burglar
y
CONT
Contractor/
RepairFacility (incl.
auto & Prop)
DETH
Death
DISB Disability
FIRE
Fire/Burned (incl.
Auto/boat & prop.)
HEAL Health/Medical
(includes life, auto & prop)
LOSS Loss (not stolen)
OTHR
Other
PH
YD
Ph
ysical
Damage/Collision
(incl. Auto & Prop.)
ROBB
Robbery
STRM Storm/Earthquake/Wind
(incl. Auto & prop)
THFT Theft (NOT including Veh-
icle/Boat
thefts)
TVTH
Total Vehicle Theft Not
Recovere
d
VAND Vandalism
VHTH Vehicle/Boat Theft (NOT
incl. theft from vehicle/boat)
WATR Water Damage (including
fi
re sprinklers)
ACBE Accelerated Benefits
ACDD Accidental Death
/Dismemberment
HO
SP
Hospitalization
SMLX Surgical
Care/M
edical
Care/Lab
/X-Ray
NHHC Nursing Home/Home
Health
Care
PRES Prescription
ROLE CODES
Code Description
CL Claimant
CI
Both Claimant & Insured
CD
Claimant
Driver
CP Claimant
Passenger
EM Emplo
y
er
IN Insured
ID Insured
Driver
IP Insured
Passenger
IE Insured
EmplEnrollee/Dependent
WT
Witness
BS Bod
y Shop
LW La
wyer/Other
LR Paralegal
LO La
w Office
IY
Insurance
Employee
IB Agent/Broker
IO Insurance
Perso
nnel
MD
Medical Doctor (MD)
MC Chiropracto
r
MA Ph
ysician’s
Assistant
MO Other
Doctor
MN Nurse
MT Ph
ysical Therapi
st
MS Dentist
MG Radiologist
MH Medical Clinic/Hospital
MZ Office Administrator
MM Other
Medical
Personnel
MX X-Ra
y Lab
MR Laborato
ry
MY
Medical
Provider/Other
OP
Other
Pr
ofessional
NP Other
Non-Profe
ssional
BE Beneficiar
y
HP Health Care Prov
ider
MP
Medical Equipment Provider
PH Pharmac
y
CR
Creditor/
Debtor
AJ Adjuster
AP Appraiser
AC
Certified Application Counselor
NV Navigator
OT Other
VEHICLE DATA
Vehicle Make: Ford, Toyota, Chevrolet
Vehicle Model: Escort, Camry, Corvette
Vehicle Style: 4-Dr., Convertible
Yo
u can also submit this Referral
through National Insurance Crime
Bureau (NICB).
If you are a member of NICB, you can
cause the referrals you submit to them to
be copied to the Arizona Department of
Insurance Fraud Unit. NICB offers
insurers the option of sending a copy of
their referrals to the appropriate State
Department of Insurance. Simply indicate
in the box provided by NICB that you
would like to have your referral copied to
the Arizona Department of Insurance.
Form F100 Rev. 03/2019
ADOI
Arizona Department
of Insurance
FRAUD REFERRAL
Page ____ of ______
ADDENDUM: Additional Role Information
ADOI USE ONL
Y
CONTROL NUMBER
Date of Preparation Insurance Company Name NAIC
Policy Number Claim Number Date of Loss
#
Role First Name Middle Name Last Name Jr/Sr/III/etc.
Name of Business, DBA or Alias Phone Number
Address City State ZIP Code
DOB SSN TIN(S)
Occupation Driver License # State
Vehicle ID Number (VIN) Year Make Model Style/Color
License Plate # Year State Type
Reported Injuries, Disease, Illness or Condition
#
Role First Name Middle Name Last Name Jr/Sr/III/etc.
Name of Business, DBA or Alias Phone Number
Address City State ZIP Code
DOB SSN TIN(S)
Occupation Driver License # State
Vehicle ID Number (VIN) Year Make Model Style/Color
License Plate # Year State Type
Reported Injuries, Disease, Illness or Condition
#
Role First Name Middle Name Last Name Jr/Sr/III/etc.
Name of Business, DBA or Alias Phone Number
Address City State ZIP Code
DOB SSN TIN(S)
Occupation Driver License # State
Vehicle ID Number (VIN) Year Make Model Style/Color
License Plate # Year State Type
Reported Injuries, Disease, Illness or Condition
CLEAR FORM
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ADOI FRAUD REFERRAL 100 N. 15th Ave, 102 (Arizona)

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Completed 12 August 2020

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