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Social Security Number
Date of Loss
Date of Birth
Please describe the allegation details
Involvement
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Agent Fraud
Application Fraud
Arson - Business
Arson - Home
Arson - Vehicle
Billing for Services/Products Not Provided
Changing Dates of Service, CPT / CPT / Diagnostic Codes
Charges Inconsistent with Services Provided
Cooperative Investigation File Request
Double - Dipping
Duplicated Billing For Same Services
Exaggerated Injuries
Failure to Disclose Multiple Insurance Companies
False Claims
Fictitious Damages
Fictitious Loss
Fictitious Theft - Property
Fictitious Theft - Vehicle
Forged Prescriptions
Fraudulent Death Claims
Illegal Solicitation (Cappers)
Inflated Damages
Inflated Loss
Inflated Theft - Property
Inflated Theft - Vehicle
Injuries Not Related To Work
Issued Fraudulent Insurance Policies, Certificates, Binders, ID Cards
Kickbacks/Bribery
Malingerers
Misappropriated Vehicle Salvage
Misrepresentation of Services/Products Provided
Misrepresented Non - Covered Services as Covered
Money Laundering
Multiple Claims
Others
Over - Utilization of Services
Paper Accidents
Possession/Sold Fraudulent Insurance Policies, Certificates, Binders, ID Cards
Premium Avoidance
Prescription Abuse / Doctor Shopping
Prescriptions Issued for Non- Medical Purposes
Prior Injuries
Products Billed are Inconsistent with the Products
Questioned Documents - Altered
Questioned Documents - Duplicated
Questioned Documents - Falsified
Questioned Documents - Forged
Received Compensation for Referral to Health Care Provider or Attorney
Ring / Organized Activity Type
Slip and Fall
Staged Collisions
Staged Injury / Accident at Work
Unbundling
Upcoding
Using Unqualified / Unlicensed Persons to Perform Billable Services
Date Allegation Observed
January
February
March
April
May
June
July
August
September
October
November
December
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2
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23
24
25
26
27
28
29
30
31
(must be four digits e.g. 2004)
10/15/2024
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Reporting Person First Name
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Reporting Person Middle Name
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Notes of Importance
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CA - California
CO - Colorado
CT - Connecticut
DE - Delaware
DC - District of Columbia
FL - Florida
GA - Georgia
HI - Hawaii
ID - Idaho
IL - Illinois
IN - Indiana
IA - Iowa
KS - Kansas
KY - Kentucky
LA - Louisiana
ME - Maine
MD - Maryland
MA - Massachusetts
MI - Michigan
MN - Minnesota
MS - Mississippi
MO - Missouri
MT - Montana
NE - Nebraska
NV - Nevada
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NY - New York
NC - North Carolina
ND - North Dakota
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
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VT - Vermont
VA - Virginia
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