Fillable For State Use Only ed fields are marked (Information Technology Section)

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For State Use Only ed fields are marked (Information Technology Section)

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The For State Use Only ed fields are marked (Information Technology Section) form is 2 pages long and contains:

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Country of origin: US
File type: PDF

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For State Use Only
IFR - Region Assigned:
Requir
ed fields are marked with an asterisk*
Referring Private Citizen Information
Check here if referr
ing anonymously and continue to Suspect Information
Name
Address
City
State
Zip Code
County
Phone Number
( )
Fax Number
( )
Email Address
Suspect Information (If additional suspects are involved please include in Summary)
Name (include any known aliases)*
Sex
Male
Female
Social Security Number
Street Address
City
State
Zip Code
County
Mobile Phone Number
( )
Home Phone Number
( )
Email Address
Address Type: Residential Business Other
Claim Information (If additional companies are involved, please include in Summary)
Insurance Company
Claim Number
Policy Number
Date of Loss
Date Claim Filed
Amount Paid
$
Fraud Allegation Summary *
In your own words, describe in as much detail as possible, what a person or business did to commit
Insurance Fraud. This section MUST be completed – attach additional pages if necessary.
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For State Use Only ed fields are marked (Information Technology Section)

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Completed 21 May 2022

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