Fillable Consumer Fraud Report Form (Montana Office of the Commissioner of Securities and Insurance, Montana State Auditor)

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Consumer Fraud Report Form (Montana Office of the Commissioner of Securities and Insurance, Montana State Auditor)

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Matt M. Rosendale
Commissioner of Securities & Insurance
Phone: 406.444.2040
Montana State Auditor
800.332.6148
840 Helena Ave
Fax: 406.444.3497
Helena, MT 59601
www.csimt.gov
Consumer Fraud Report Form
Your Information:
Last First
Phone #
E-mail Address
Street/Apartment # City
Suspect Information:
State
ZIP Code
Last First
Phone#
E-mail Address
Street/Apartment # City
State
ZIP Code
Insurance
Company/Agent Information (if applicable):
Company/Agent Name
Phone#
Contact Person
Street/Apartment # City
State
ZIP Code
Policy#
Claim#
Nature of Suspected Fraud:
Describe the nature of the suspected fraud. Please include as much information as you can
about the type of insurance involved, the dates the suspected fraud occurred and a description of the
suspected fraud. If more space is needed you may attach a separate document:
High Pressure Sales Techniques
Misrepresentation of Facts/Policy
Misuse or Missing Premium
Staged Accident/Injury
History of Filing Suspect Claims
Faked Property Damage or Injury
Billed for Services Not Provided
Billed for Excessive or Extended Treatments
Inflated Financial Loss
Charged Inconsistent with Services Provided
Other:
Yes No If yes, please describe:
Do you have any reason to believe this incident is related to other fraudulent activity, has
been reported to another law enforcement or government agency, or there is a pending
legal action?
Ways to submit
this form:
By Fax: (406) 444-3497
By E-mail:
By mail:
Investigations Bureau
Office of the Commissioner of Securities & Insurance
Montana State Auditor
840 Helena Avenue
Helena, MT 59601
All information will be kept confidential
tbidon@mt.gov
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Consumer Fraud Report Form (Montana Office of the Commissioner of Securities and Insurance, Montana State Auditor)

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Completed 27 January 2021

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