DIFS - DIFS Online Fraud Complaint Form

*Required field

Department of Insurance and Financial Services

Fraud Complaint Form

Filing this form is restricted to legitimate business purposes only. Information will be submitted to the Michigan Department of Insurance and Financial Services (DIFS) Fraud Investigation Unit (FIU) for their review and investigation. DIFS bears no responsibility or liability for the accuracy or veracity of information submitted. Users reporting fraudulent activity through this form will do so in good faith.

By clicking in the box next to the, “I agree to the language above”, you acknowledge the following: that you have read and understand this statement regarding the use of this form; that access or use of this form for fraudulent activity is strictly prohibited by the State of Michigan and the Department of Insurance and Financial Services; that use of this form or the reporting of suspected fraudulent activity which you know to be false, may subject you to criminal or civil penalties/remedies under state, federal, or other applicable domestic and foreign laws.

* I agree to the language above.

Person Reporting Suspected Fraud

YOU MAY REPORT ANONYMOUSLY: No personal identifying information is required to submit an allegation of suspected fraud. For those individuals wishing to receive verification of DIFS receipt of the report, please provide your name and e-mail address. You may also choose to provide additional contact information to facilitate additional communication from DIFS Fraud investigation Unit or other investigating authorities.

Voluntary Contact Information of Person Reporting Suspected Fraud

*I would like to remain anonymous:Yes
No

First Name:

Last Name:

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

County:

Email Address (required if you would like a confirmation email):

Home Phone Number:

Cell Phone Number:

Description of Suspected Fraud

Please provide the following information on the individual or entity that you suspect committed fraud, including identifying the industry, person, or business entity and other details.

Industry Type:

Business Name:

First Name:

Last Name:

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Phone Number:

If you have any further comments or subject information, please use this space for additional identifying information about the subject:

Date of Suspected Loss:

Amount of Loss:

Description of Suspected Fraud:

NOTE: The Following Section Is For Insurance Fraud Complaints Only

Please skip to the “Identify Other Agencies You Have Contacted Regarding This Referral” if your submission is not regarding insurance fraud.

Case Details and Claim/Incident Information for Insurance Fraud Complaints

In this section please provide additional information about the suspected insurance fraud including other investigations, litigation, claim, policy and financial information, etc.

If you are a consumer, please complete as much of this section as possible. If you are a memnber of the industry, please complete this section in its entirety.

SIU Investigation Completed:Yes
No

Date SIU Investigation Completed:

SIU Case Number:

Civil Litigation Pending:Yes
No

Is there any reason to believe that this incident is related to other suspected fraudulent activity?Yes
No

If yes, please explain:

Claim Number:

Policy Number:

Insurance Company Case Number:

Insurance Type:

Potential Loss Amount:

Amount Paid:

Date Paid:

Billed Amount:

Settlement Amount:

Settlement Date Paid:

Reserve Amount:

Claim Status:

Date of Service Start:

Date of Service End:

Description of Service:

Procedure Code Type:

Procedure Codes:

Date of Loss/Injury:

Loss Address Line 1:

Loss Address Line 2:

Loss City:

State:

Loss Zip Code:

Loss County:

Identify Other Agencies You Have Contacted Regarding This Referral

Please list other from above:

Agency Contacted:

Contact Person:

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Telephone Number:

Fax Number:

Email:

Case/Claim Number:

Description of communications with other agencies:

*Add five plus one and type the answer here: