Fillable Suspected Insurance Fraud Report (Arizona)

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Suspected Insurance Fraud Report (Arizona)

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The Suspected Insurance Fraud Report (Arizona) form is 4 pages long and contains:

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Suspected Insurance Fraud Report
V.DIFI
-
Fraud
-
1120
2
1
Instructions
Use this form to report suspected insurance fraud to the Arizona Department of Insurance and Financial Institutions
(DIFI). You may send the form by:
Mail: DIFI Insurance Fraud Unit, 100 N. 15
th
Ave, #102, Phoenix AZ 85007
Email: Investigations@difi.az.gov
Important information
This report is for Arizona residents, Law Enforcement, and other non-Insurance industry entities wanting to
report suspected insurance fraud to the Department of Insurance and Financial Institutions.
This report DOES NOT MEET the state law requirements for Arizona licensed insurance companies required to
report suspected insurance fraud to DIFI. Insurance companies must report via NAIC Online Fraud Reporting
Systems OFRS, or through NICB.
For more information, visit https://difi.az.gov/fraud-00 or call us at 602-364-2140.
Information about you (You do not have to fill out this section)
Name
First name Last name
Address
Street address City State ZIP
Phone number Email
Today’s date
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Suspected Insurance Fraud Report
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Information about the suspects (Who you believe committed fraud)
Provide as much information as you can. This helps us identify the right suspect. For any item you may not
know, please leave the line empty.
Name
First name Middle name Last name
Address
Street address City State ZIP
Phone number Email
Occupation Employer
Gender ☐ Male ☐ Female Alias (AKA)
Information about other suspects
Fill out this information if there are other suspects. Use multiple pages if you need to. For any item you may not
know, leave the line empty.
Name
First name Middle name Last name
Address
Street address City State ZIP
Phone number Email
Occupation Employer
Gender ☐ Male ☐ Female Alias (AKA)
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Information about Insurance company involved
Fill out this information regarding the Insurance company being victimized or defrauded. Use multiple pages if
you need to. For any item you may not know, leave the line empty.
Company Name
Type of Insurance Company
Medical/Automotive/Homeowners
Address
Street address City State ZIP
Company Representative Name
First name Last name
Phone number Email
Occupational Title:
Agent /Customer Service Rep / Adjuster
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Suspected Insurance Fraud Report
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Information about the suspected fraud
When did the fraud happen?
Provide a brief summary of what happened. Please list any witnesses you know about.
If you have any supporting documents or other evidence, please attach them to this report.
The Arizona Department of Insurance and Financial Institutions, Fraud Unit is a Law
Enforcement Agency. Providing false information to a law enforcement agency about a crime
is punishable up to 6 months in Jail, $4,575.00 fine and/or up to 3 years probation.
ARS 13-2907.01, ARS 13-707.1, ARS 13-802.A, ARS 13-902.5
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Suspected Insurance Fraud Report (Arizona)

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Completed 1 July 2022

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