Insurance Fraud Industry Referral Form www.attorneygeneral.gov Insurance Fraud Section th 16 Floor, Strawberry Square Harrisburg, PA 17120 717-787-0272 For State Use Only IFR Region Assigned: Required fields are marked with an asterisk* Referring Agency Information Contact Person* Agency Name* Address * City * State* Zip Code * County * Phone Number * ( ) Fax Number * ( ) Email Address * Subject Information (If additional subjects are involved please include in Summary) Name (include any known aliases)* Date of Birth Sex Male Female Social Security Number Street Address City State Zip Code County Mobile Phone Number ( ) Residential Home Phone Number ( ) Business Other Email Address Address Type: Referral Status Have you referred this to any other law enforcement agency If yes, identify Agency and Contact Person: Yes No Reason why you are sending this matter to our office: Requesting an investigation For informational purposes only American LegalNet, Inc. www.FormsWorkFlow.com Location (Counties and/or States ­ DO NOT PUT DATES IN THIS SECTION) Incident occurred in: Insurer payment sent from: Claim was received in: Payment was sent to subject at: False statement made: Claim Information (If additional companies are involved, please include in Summary) Policy Number Claim Number Policy Limits $ Date Claim Made Date of Loss Amount Claimed Amount Paid Status of claim: Paid Denied Withdrawn Pending Settled Other If other, please state: Type of Insurance/Fraud Involved: Auto Rate Evasion Homeowners/Renters Commercial Health Disability Life Workers Compensation Agent/Fraud Company Other If other, please state: Fraud Allegation Summary In your own words, describe in as much detail as possible, what a person or business did to commit Insurance Fraud. This section MUST be completed ­ attach additional pages if necessary. American LegalNet, Inc. www.FormsWorkFlow.com