UNIFORM SUSPECTED INSURANCE FRAUD REPORTING FORM
State of District of Columbia
Department of Insurance, Securities and Banking
Enforcement and Investigation Bureau
For State Use Only
Case No.
Status
FYI
Contact:
gregory.marsillo@dc.gov
; (202) 727−1564
Reporting Person:
Insurance Company:
NAIC #:
Phone Number:
Mailing Address:
Fax Number:
E−mail Address:
Detailed synopsis. Attach additional pages, if necessary
Date of Loss / Injury:
Dates of Service:
To:
Address of Loss / Injury:
Description of Service:
City:
State:
Zip:
Claim #:
Policy #:
CPT
CDT
Insurance Type:
Reserve Amount
Amount Paid
Date Paid
Procedure Code #'s
PC
WC
HC
Auto
Loss Amount
Settlement
Date Paid
Civil Litigation Pending:
Yes
No
Life
Disability
Subject Information
Type:
Name (Last/Business):
(First):
(Middle):
Date of Birth:
Age:
SSN:
Fed.
TIN
EIN
Sex:
Street Address (Include P.O. Box and Apartment #'s:)
Address
Type:
Res.
Maildrop
Bus.
Other
Number:
M
F
Phone Type:
City:
State:
Zip:
County:
Phone Number:
Home
Cell
Bus.
Phone Type:
Driver's License #:
State:
VIN:
Phone Number:
Home
Cell
Bus.
Vehicle Year:
Make:
Model:
License Plate #:
Reported Injuries:
Employer:
Address & Phone:
Occupation:
See
Additional Party Involved/
AKA Information
Additional Party Involved
Comments:
AKA Information
Case Details (check all that apply)
SIU Investigation Completed?
Yes
No
Date Completed:
Is there any resson to believe that this incident is related to other fraudulent activity?
Yes
No
Statements (Witness/Insured/Subject)
EUO / Deposition
Law Inforcement Other Agency Reports
Sworn
Recorded
Copies of Receipts
Claim History Extracts
Proof of Loss
Expert Reports
IME Reports
Continuance of Disability Forms
Videos / Photos
Investigative Reports
Medical Records
Claim Information
External Database Results
Other
Other
Other
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Identify Other Agency You Have Contacted Regarding This Referral
Agency Type:
Other State Fraud Bureau
Law Enforcement
Other Insurance Company
Regulatory Agency
Other
Agency:
Contact Person:
Address:
City:
State:
Zip:
Phone Number:
Fax Number:
Case/Claim No.:
Fraud Types (check all that apply)
Arson
Agent Fraud
Duplicate billing for same service
home
vehicle
business
Application Fraud
Forged prescriptions
Fictitious
Billing for services/products not
provided
Fraudulent death claims
loss
damage
Over−utilization of services
Fictitious theft
Failure to disclose multiple insurance
companies
Prescription abuse / doctor shopping
vehicle
property
Prescriptions issued for non−medical
purposes
Inflated inventory
False claims
Inflated
Illegal solicitation (cappers)
Unbundling
loss
damage
Issued fraudulent insurance policies,
certificates, binders, ID cards
Upcoding
Inflated theft
Misrepresented non−covered
services as covered
vehicle
property
Misrepresentation of service/product
provided
Double−dipping
Changing dates of service,
CPT/CDT
/diagnostic
codes
Exaggerated injuries
Kickbacks/bribery
Injuries not related to work
Money laundering
Charges inconsistent with services
provided
Malingerers
Multiple claims
Missappropriated vehicle salvage
Possession/sold fraudulent insurance
policies, certificates, binders, ID cards
Products billed are inconsistent
with
the products
Premium avoidance
Prior injuries
Questioned documents
Using unqualified
/unlicensed
persons
to perform billable services
Slip and fall
altered
forged
Staged injury / accident at work
falsified
duplicated
Other
Staged Collisions
Received compensation for referral to
health care provider or attorney
Paper accidents
Other
Ring / organized activity type
Subject / Additional Party Types
CL
IN
WT
LC
LI
INS
SI
IY
IB
IS
IR
BS
SY
TY
MD
DO
DEN
Claimant
Insured
Witness
Lawyer for Claimant
Lawyer for Insured
Insurer
Self−Insured
Insurance Company Employee
Agent/Broker
Adjuster
Appraiser
Body Shop
Salvage Yard Owner / Employee
Tow Yard Owner / Employee
Medical Doctor
Doctor of Osteopathic Medicine
Dentist
PH
CHI
NP
LPN
PT
PA
OP
PO
RD
MT
AMB
DME
HHA
MR
MH
MZ
BS
Pharmacist
Chiropractor
Nurse Practitioner
Licensed Practical Nurse
Physical Therapist
Physician’s Assistant
Optometrist
Podiatrist
Radiologist
Message Therapist
Ambulance Service Employee
DME Supplier
Home Health Agency
Laboratory
Medical Clinic/Hospital
Office Administrator
Billing Services
TPA
FP
UP
MN
MS
Third Party Administrator
False Provider
Unlicensed Provider
Other Medical Personnel
Medical Specialist
DS
Dental Specialist
NS
Nurse Specialist
OT
Other
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Additional Party Involved / AKA Information
Type:
Name (Last/Business):
(First):
(Middle):
Date of Birth:
Age:
SSN:
Fed.
TIN
EIN
Sex:
Street Address (Include P.O. Box and Apartment #'s:)
Address
Type:
Res.
Maildrop
Bus.
Other
Number:
M
F
Phone Type:
City:
State:
Zip:
County:
Phone Number:
Home
Cell
Bus.
Phone Type:
Driver's License #:
State:
VIN:
Phone Number:
Home
Cell
Bus.
Vehicle Year:
Make:
Model:
License Plate #:
Reported Injuries:
Employer:
Address & Phone:
Occupation:
Involvemenent in referral:
Additional Party Involved / AKA Information
Type:
Name (Last/Business):
(First):
(Middle):
Date of Birth:
Age:
SSN:
Fed.
TIN
EIN
Sex:
Street Address (Include P.O. Box and Apartment #'s:)
Address
Type:
Res.
Maildrop
Bus.
Other
Number:
M
F
Phone Type:
City:
State:
Zip:
County:
Phone Number:
Home
Cell
Bus.
Phone Type:
Driver's License #:
State:
VIN:
Phone Number:
Home
Cell
Bus.
Vehicle Year:
Make:
Model:
License Plate #:
Reported Injuries:
Employer:
Address & Phone:
Occupation:
Involvemenent in referral:
Additional Party Involved / AKA Information
Type:
Name (Last/Business):
(First):
(Middle):
Date of Birth:
Age:
SSN:
Fed.
TIN
EIN
Sex:
Street Address (Include P.O. Box and Apartment #'s:)
Address
Type:
Res.
Maildrop
Bus.
Other
Number:
M
F
Phone Type:
City:
State:
Zip:
County:
Phone Number:
Home
Cell
Bus.
Phone Type:
Driver's License #:
State:
VIN:
Phone Number:
Home
Cell
Bus.
Vehicle Year:
Make:
Model:
License Plate #:
Reported Injuries:
Employer:
Address & Phone:
Occupation:
Involvemenent in referral:
Submit
Reset
Go
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