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Department of Insurance, Securities and Banking

Insurer Fraud Form Instructions

These directions provide a general explanation of the information that you need to add to sections of the form. For sections that ask a variety of information (such as phone number, driver's license number, address), complete the form as it relates to the person/business mentioned in the Subject section, so that the insurance fraud division can track the information. If the subject has an alias with different dates of birth or other details, please place this information in the Additional Parties section of the form so investigators can differentiate between the personal data connected to each subject name.