Fillable Insurance Fraud Report Suspected Matt M. Rosendale Commissioner (Montana Office of the Commissioner of Securities and Insurance, Montana State Auditor)

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Insurance Fraud Report Suspected Matt M. Rosendale Commissioner (Montana Office of the Commissioner of Securities and Insurance, Montana State Auditor)

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Billed for Services Not Provided
Billed for Excessive or Extended Treatments
Fabricated Services
Charged Inconsistent with Services Provided
Other:
Matt M. Rosendale
Commissioner of Securities & Insurance
Montana State Auditor
840 Helena Ave
Helena, MT 59601
Phone: 406.444.2040
800.332.6148
Fax: 406.444.3497
www.csimt.gov
Report Suspected
Your Information:
Insurance Fraud
Last First Phone # E-mail Address
St
reet/Apartment #
Suspect Information:
City State ZIP Code
Last F
irst M.I. Date of Birth
St
reet/Apartment # City State ZIP Code
Nature of Suspected Fraud:
Faked Property Damage
Inflated Financial Loss
Faked/Exaggerated Injury
Staged Accident/Injury
History of Filing Suspect Claims
Provided an Inaccurate History
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:
Page 1 of 2
Do you have any reason to believe this incident is related to other fraudulent activity?
Yes No If yes, please describe:
Is this an i
nsurance company referral?
No Yes - Please include the following:
Insurance Company Contact Person Phone
Address City State ZIP Code
Ways to submit
this form:
By Fax: (406) 444-3497
By E-mail: TBidon@mt.gov
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
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Insurance Fraud Report Suspected Matt M. Rosendale Commissioner (Montana Office of the Commissioner of Securities and Insurance, Montana State Auditor)

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Completed 20 July 2020

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