Report Suspected Fraud (Insurance Companies)

The State Fire Marshals Office invites anyone with information regarding Insurance Fraud to submit information about the crime through this website online tip form.  The information will be relayed directly to the State Fire Marshals Office.  The information you provide will be maintained in the strictest of confidence.

NOTE! This form is intended to be utilized by insurance companies reporting insurance fraud. 

Fraud Tip Line: 1-800-654-0775

	*  Required
Reporting Agency
* Company Submitting Report:
* Company Address:
* City:	Select State AK AL AR AZ CA CN CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
* Contact's First Name:
MI:	MI A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
* Contact's Last Name:
* Contact's Title:
* Contact's Telephone:
* Contact's Email Address:
Primary Suspect
* First Name:
MI:	MI A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
* Last Name:
* Date of Birth:	(MM/DD/YYYY)
Telephone:
Known Address:
City:	Select State AK AL AR AZ CA CN CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Claim No:
Policy No:
Secondary Suspect
First Name:
MI:	MI A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
Last Name:
Date of Birth:	(MM/DD/YYYY)
Telephone:
Known Address:	Same as Primary Address
City, State, Zip:	Select State AK AL AR AZ CA CN CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Claim No:
Policy No:
* Status of the Claim:	Select Status Active Closed Denied Pending
* Total payments made, to date:	(Ex. 5000)
* Total financial exposure:	(Ex. 5000)
* Has the person retained legal representation?	YesNo
Evidence available:	Statements/Transcripts
	SIU Reports
	Photos
	Witness Information
	Other
If other, give description:
* Summarize why this is fraud: