Fillable Form 16: www.attorneygeneral.gov Insurance Fraud Industry Referral Form (Information Technology Section)

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Form 16: www.attorneygeneral.gov Insurance Fraud Industry Referral Form (Information Technology Section)

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The Form 16: www.attorneygeneral.gov Insurance Fraud Industry Referral Form (Information Technology Section) form is 2 pages long and contains:

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File type: PDF

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www.attorneygeneral.gov
Insurance Fraud Industry
Referral Form
Insurance Fraud Section
16
th
Floor, Strawberry Square
Harrisburg, PA 17120
717-787-0272
For State Use Only
IFR - Region Assigned:
Requ
ired fields are marked with an asterisk*
Referring Agency Information
Contact Person*
Agency Name*
Address *
City *
State*
Zip Code *
County *
Phone Number *
( )
Fax Number *
( )
Email Address *
Sub
ject Information (If additional subjects 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
Refer
ral Status
Have you referred this to any other law enforcement agency Yes No
If yes, identify Agency and Contact Person:
Reason why you are sending this matter to our office:
Requesting an investigation For informational purposes only
Location (Counties and/or States – DO NOT PUT DATES IN THIS SECTION)
Incident occurred in:
Insurer payment sent from:
Claim was received in:
Payment was sent to subject at:
False statement made:
Claim Information (If additional companies are involved, please include in Summary)
Policy Number
Claim Number
Policy Limits
$
Date of Loss
Date Claim Made
Amount Claimed
Amount Paid
Status of claim:
Paid
Denied
Withdrawn
Pending
Settled
Other
If other, please state:
Type of Insurance/Fraud Involved:
Auto
Rate Evasion
Homeowners/Renters
Commercial
Health
Disability
Life
Workers Compensation
Agent/Fraud Company
Other
If other, please state:
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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Form 16: www.attorneygeneral.gov Insurance Fraud Industry Referral Form (Information Technology Section)

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Completed 21 May 2022

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