GENERAL PUBLIC Suspected Insurance Fraud Information Report INSTRUCTIONS If you are a concerned citizen who wishes to report suspected insurance fraud, please PRINT, FILL OUT and MAIL the below Insurance Fraud Information Report and provide the following information: 1. Your complete name, home and work telephone numbers and addresses, and any times and place you prefer to be contacted; 2. The addresses and telephone numbers of the person(s) involved if known. Any other identifying information would be helpful, i.e., social security number, license plate numbers, etc.; 3. Where the suspected person(s) work; 4. The name of the insurance company you suspect is being defrauded; and, 5. The date, location and time of the occurrence. 6. Please provide information of each and every detail you can of why you believe insurance fraud has been committed by the above person(s). Are there any other witnesses whom we may contact? It would be very helpful if you could provide us any documents you have in your possession and/or can obtain which would support your suspicions regarding the above. We Cannot Accept electronic transmissions of the form. After you have completed your form, please mail (along with documentation) to: Office of the Attorney General Insurance Fraud Unit 555 E. Washington Avenue, Suite 3900 Las Vegas, NV 89101 Once again, the Nevada Attorney General’s Insurance Fraud Unit thanks you for your concern and cooperation. Sincere regards, CATHERINE CORTEZ MASTO Attorney General American LegalNet, Inc. www.FormsWorkflow.com Date_________ Insurance Fraud Information Report Your Name Day Phone: Your Address Evening Phone: ______ Fax #: Your Place of Employment: May we contact you at work? YES NO Best time to contact you? Suspect(s) Information Complete name of person(s) you suspect is committing insurance fraud: (Please include any nicknames or aliases) Suspect(s) Address: Phone #’s (Work address) Identifying Information such as Social Security Number(s), License Plate(s), Year/Make of Vehicle(s), etc. Name and addresses of other involved persons or persons who can provide additional information: Name of insurance company you suspect is being defrauded? Comments and details regarding why you feel insurance fraud is being committed? Use reverse side or separate sheet of paper for additional information. Thank you for taking time to complete this form. PLEASE RETURN THIS FORM TO: INSURANCE FRAUD UNIT Office of the Attorney General 555 E. Washington #3900 Las Vegas, NV 89101 American LegalNet, Inc. www.FormsWorkflow.com