Insurance Fraud Private Citizen Referrals 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 Private Citizen Information Check here if referring anonymously and continue to Subject Information 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: Claim Information (If additional companies are involved, please include in Summary) Insurance Company Claim Number Policy Number Date of Loss Date Claim Filed Amount Paid $ American LegalNet, Inc. www.FormsWorkFlow.com 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