Mail or fax form to: Insurance Fraud Bureau Iowa Insurance Division 330 Maple Street Des Moines, Iowa 50319-0065 Phone: 515-242-5304 FAX: 515-242-5303 www.iid.state.ia.us/Division/Fraud
For Office Use Only Date Received Case Number
INSURANCE FRAUD COMPLAINT FORM PERSON REPORTING Name: Address: Home Phone: Work Phone: Hours that we may contact you there: SUBJECT Name: Address: Place of Employment: Address: Work Phone Number: Vehicle description/plate no.: Is the subject the insured? Yes If not, who is?
Fraud Type (check all that apply): Arson - (circle one) home / vehicle / business Claim investigation, resulting in denial, reduction, withdrawal Double-dipping (compensated and working) Faked / exaggerated damages Faked / exaggerated injuries Fictitious loss/damages (ex. water damage) Fictitious theft vehicle Fictitious theft property Inflated inventory Inflated loss/damages Inflated theft vehicle Inflated theft property Injuries not related to work Malingerers Misappropriated vehicle salvage Misrepresentation of services / products provided Premium avoidance Prior injuries Slip and fall Staged injury / accident at work Staged/caused accidents Agent fraud Application fraud Billing for services not rendered (ex. repairs, medical treatment) Failure to disclose multiple insurance companies False claims Illegal solicitation hired or paid cappers/chasers Involved in other suspicious claims/activity Issued fraudulent insurance policies, certificates, binders, ID cards Kickbacks/bribery Money laundering Multiple claims Possession/sold fraudulent insurance policies, certificates, binders, ID cards Questioned documents (circle all that apply) altered, forged, falsified, duplicated Received compensation for referral to health care provider or attorney Ring / organized activity type Other Duplicate billing for same service Forged prescriptions Fraudulent death claims Misrepresentation (check all that apply): Billing for treatment as payable when it is not payable Changing dates of service, procedures or diagnosis code Charges inconsistent with services provided Products billed are inconsistent with the products provided Using unqualified persons to perform billable services Prescription abuse / doctor shopping
Date of Birth (age): Home Phone Number:
No
Witnesses/other parties involved? Yes Name(s): Address: Phone Number: Place of Employment: Comments:
No
Insurance company/companies involved? Yes If yes, name and address of company: Law enforcement contacted? Yes Agency: Contact person: Phone number: Date(s) that fraud occurred: Location of loss/incident: Value of claim/loss: Why do you suspect fraud? No
No
Case No.:
_____________________ Signature
IFB-02a.doc
_________________ Date