Report Insurance Fraud

Insurance Fraud Information

Please complete this form to the extent possible.

Name Person/Company Suspected of Fraud (Optional)

Address (Optional)

City (Optional)

State (Optional)

Zip (Optional)

Phone (Optional)

Date of Birth (if person) (Optional)

Month (Optional)

Day (Optional)

Year (Optional)

Name of RLI entity/insurance company that is the target/victim of suspected fraud: (Optional)

Claim Number (Optional)

Policy Number (Optional)

Brief Description of Suspected Fraud (Optional)

Your Contact Information

Although we encourage you to provide us with your contact information, it is not required to complete and file this report. Your contact information will remain anonymous throughout our investigation.

Your Name (Optional)

Your Email (Optional)

Your Address (Optional)

Your City (Optional)

Your State (Optional)

Your Zip (Optional)

Your Phone (Optional)

May we contact you with additional questions or to discuss further? (Optional)

Yes

No

Report Fraud

Insurance Fraud Information

Your Contact Information

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