Skip to main content

Please provide as much information as possible.

Your Information
* Denotes required fields

First Name *
Last Name *
Insurance Company *
NAIC# *
Street Address*
City *
State *
ZIP *
Phone *
Email *
Phone Type: *

Case Details
SIU Investigation Complete
Date Completed
SIU Case #

Civil Litigation Pending
 


Information about the Individual/Business Suspected Committing Fraud

Subject Type *        Is this an:    *

Last Name or Business Name *
First Name
Middle
Street Address *
City *
State *
Zip

Phone
Email
DOB
SS#
VIN
License Plate # / State
Vehicle Year
Make
Model
 
    Phone Type:
 
 


Claim/Incident Information

Claim #
Policy #

Insurance Type*





Claim Denied?

Date of Loss
Claim Amount
Amount Paid



 
Location of Loss
Street Address
City
State*
ZIP

Law Enforcement Agency Information

Is any LAW ENFORCEMENT AGENCY involved? If No, skip to the next section

Name of Agency
Investigating Officer
Officer's Phone
Date of Report
Report #
 

Suspected Fraud Type

Please select one or more that apply *


  Application/Eligibility fraud Arson
          













  Fictitious theft
       



  Inflated theft
       





























Information on Additional Individual/Business

Subject Type:        Is this an:       


Last Name or Business Name
First Name
Middle
Street Address
City
State
ZIP
Phone
Email
DOB
SS#
VIN
License Plate # / State
Vehicle Year
Make
Model
    Phone Type:    
 

Reason for Referral

Provide facts about the suspected fraud such as *
    What happened?
    How did you find out about it?
    Why do you think it is insurance fraud?


2500 Char Max

Files to upload


Select a file (.doc, .docx, or .pdf) to attach


Agree and Submit

To the best of my knowledge, the information contained herein is true and accurate. I understand that the information I have supplied may be used as part of an Idaho Department of Insurance inquiry or investigation, or may be given to other local, state, or federal agencies.
Please check the box below to indicate that you agree to the statements in this paragraph.

I Agree

If you would like a copy of your complaint please PRINT it before hitting the “Submit” button. Please click on Submit Complaint only once, and wait patiently. It may take some time for our system to process your entry. You will receive a confirmation if the form has successfully completed.