Insurance Fraud Report Form

Insurance Fraud Report Form

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Insurance Fraud Report Form

 

INSTRUCTIONS: CONNECTICUT INSURANCE FRAUD REPORT 

 

 

When insurance fraud has been reported and documented in Connecticut, the insurance fraud report discussed this article must be filed. This document can be obtained from the website maintained by the government of the state of Connecticut.

 

Connecticut Insurance Fraud Report Step 1: There are six columns that should be filled in as applicable throughout the first page of the form. Column A concerns auto insurance, column B concerns workers' compensation insurance, column C concerns life insurance, column D concerns accident and health insurance, column E concerns other types of insurance, and column F is for the total of columns A through E reported on each line.

 

Connecticut Insurance Fraud Report Step 2: On line 1, enter the number of policies in force excluding group plans.

 

Connecticut Insurance Fraud Report Step 3: On line 1a, enter the number of plan members enrolled in group plans only.

 

Connecticut Insurance Fraud Report Step 4: On line 2, enter the number of claims received excluding group plans.

 

Connecticut Insurance Fraud Report Step 5: On line 2a, enter the number of claims received from group plans only.

 

Connecticut Insurance Fraud Report Step 6: On line 3, enter the number of cases of suspected fraud accepted by the SIU. On line 3a, enter the number of policy applications referred to the SIU. On line 3b, enter the number of claim cases referred to the SIU. On line 3c, enter the number of other cases referred to the SIU.

 

Connecticut Insurance Fraud Report Step 7: On line 4, enter the amount of money not paid on fraudulent cases.

 

Connecticut Insurance Fraud Report Step 8: On line 5, enter the amount of money recovered on fraudulent cases.

 

Connecticut Insurance Fraud Report Step 9: On lines 6a through 6f, enter the number of cases referred to authorities by type. Document insured/policyholder fraud cases on line 6a, claimant/member fraud cases on line 6b, agent/employee fraud cases on line 6c, medical provider fraud cases on line 6d, legal provider fraud cases on line 6e, and other fraud cases on line 6f.

 

Connecticut Insurance Fraud Report Step 10: The person preparing the form should enter their name, the date, their signature, their title and their telephone number where indicated. The SIU director or comparable manager should also sign and date the form where indicated.


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