Insurance Fraud is a Felony

21 SAMPLE State of California, Department of Insurance, Fraud Division Consumer Insurance Fraud Reporting Form. This form is designed to be used by members of the general public and their representatives. If you are employed in the insurance industry you must use Form FD-1 to make your report. Under California Insurance Code Section 1879.5, no person shall be subject to civil liability for filing a good faith report of suspected insurance fraud to the Department of Insurance. SECTION 1—REPORTING PARTY Anonymous Date Last Name ________________________________________ First Name _______________________________________________ Email Address _____________________________________ Company Name ____________________________________ DBA ____________________________________________________ Street Address _____________________________________ City ____________________________________________________ State ________________ Zip Code _____________ Contact Phone # ___________________________________________ SECTION 2—INSURANCE FRAUD INFORMATION (Please Provide Known Information) Insurance Company (s) ____________________________________________________________________________ Policy # _________________________________________ Claim # ________________________________________ Date of Loss ____________________________ Is Fraud Still On Going? Yes No Location of Loss: City ____________________________ Zip Code __________________ Person listed below is: Insured Claimant Suspect Other Last Name ______________________________________ First Name ______________________________________ Street Address ___________________________________ City ___________________________________________ State __________________ Zip Code ________________ Phone # ________________________________________ Company Name _________________________________ DBA ___________________________________________ Person listed below is: Insured Claimant Suspect Other Last Name _____________________________________ First Name _______________________________________ Street Address __________________________________ City ____________________________________________ State ______________________ Zip Code ___________ Phone # _________________________________________ Company Name ________________________________ DBA ____________________________________________ SECTION 3—This Information Has Also Been Referred To: Has an insurance company been notified of this activity? Yes No If yes, listed company ________________________________________________________ Has a law enforcement agency been notified of this activity? Yes No If yes, listed agency (s) _______________________________________________________ Has a District Attorney’s Office been notified of this activity? Yes No If yes, listed county __________________________________________________________ Have other agency (s) been notified of this activity? Yes No If ye, listed agency (s) ________________________________________________________ Rev. 7/11/11