Auto Insurance Fraud Online Complaint Form

Please complete this form with as much information and in as detailed a manner as possible.

Your name

Email

Daytime phone

County/zip code

Section I

What type of provider or professional is involved: (check all applicable) provider or professional

Medical Clinic/ Physician

Attorney

Staged Accident

Runner/ Steerer

Auto Repair Shop

Insurance Broker

Pharmacist

Address of provider/professional:

Location of fraudulent activity (if different than provider’s address):

Date and time of fraud:

Insurance policy and claim number

Names of individuals involved in fraud:

In your own words, describe in as much detail as possible, what a person or business did to commit insurance fraud.