Provide information such as names, details, alias, social security/insurance number(SSN or SIN), driver's license number, Date of birth or approximate age?

What kind of insurance is it? (Ex. Property and Casualty, Worker's Compensation, Auto Liability, Health Insurance, Medicaid, etc.)

Could you please provide the insurance company name?

About the fraudulent activity or event

Why do you think this may be a fraudulent claim?

Do you have any documents that would help to prove that this claim is fraudulent?

Let us know any additional information that may be helpful:

You may remain anonymous, but if you wish to leave your name and daytime phone number, please do indicate its nature.

Last Name:

First Name:

Email:

Telephone Number:

VERY IMPORTANT - PLEASE READ

By clicking on the provided check box, I acknowledge that I fully understand that intentional submission of a false tip to the Law Enforcement Agencies, such as the police, is a serious criminal offence and punishable by law. I further acknowledge that the information I am provided herewithin this form, is accurate to the best of my knowledge.