1. (a) Fraud and referral type

   1. (1) Fraud type
   2. (2) New referral/amended referral indicator

2. (b) Reporting party information

   1. (1) Two-digit reporting party code, as follows:

3. (A) Carrier/licensed insurer:

   01

4. (B) Private sector self-insured:

   02

5. (C) Public sector self-insured:

   03

6. (D) Third party administrator:

   04

7. (E) State Compensation Insurance Fund (SCIF):

   1. (2) Reporting party name
   2. (3) Reporting party California Certificate of Authority number
   3. (4) Reporting party self-insured or contracted third party license number, as appropriate
   4. (5) Reporting party address, city, state, and zip code
   5. (6) Reporting party email address (generally, contact address)
   6. (7) Reporting party Federal Employer Identification Number

   7. (c) Alleged victim information, as appropriate

      1. (1) Alleged victim company name
      2. (2) Alleged victim California Certificate of Authority number
      3. (3) Alleged victim self-insured or contracted third party license number, as appropriate
      4. (4) Alleged victim address, city, state, and zip code

   8. (d) Insurance policy or claim information, as appropriate

      1. (1) Claim number associated with referral
      2. (2) Insurance policy number associated with referral
      3. (3) Date of loss or injury
      4. (4) Geographic location where loss or injury occurred
      5. (5) Insurance premium dollar loss
      6. (6) Total potential loss on claim prior to the identification of fraud
      7. (7) Total claim loss paid to date
      8. (8) Actual suspected fraudulent loss amount paid to date

      9. (9) The complete summary of all the facts on which the reasonable belief of the insurance fraud is based, that has been prepared pursuant subdivision (a)(5) of Section 2698.36.

         1. (A) The summary shall include the following information, if known:

            1. 1. The facts that caused the reporting party to believe insurance fraud occurred or may have occurred.
            2. 2. The suspected misrepresentations and who it was that allegedly made them.
            3. 3. How the alleged misrepresentations are material and how they affect the claim or insurance transaction.
            4. 4. Identification of pertinent witnesses to the alleged misrepresentation.
            5. 5. What documentation there is of the alleged misrepresentation.
         2. (B) In addition, the summary prepared pursuant to this subdivision (d)(9) shall include a statement as to whether or not the investigation is complete.
      10. (10) Disaster claim indicator

   9. (e) Other agency referral information, as appropriate

      1. (1) Names of other authorized governmental agencies receiving this referral
      2. (2) Names of any District Attorney's Office receiving this referral
      3. (3) National Insurance Crime Bureau (NICB) referral indicator
      4. (4) The names of any other agencies receiving this referral

   10. (f) Referral contact information, as appropriate

       1. (1) Referral contact name, title, and phone number
       2. (2) Claim or case file handler and phone number
       3. (3) Name and phone number of person who completed referral
       4. (4) Date referral was completed (not required if submitted electronically)

   11. (g) Information for each party associated with the referral

       1. (1) Name of party and identification of the role of the party to the loss
       2. (2) Phone number
       3. (3) Address, city, state, and zip code
       4. (4) Date of birth or age
       5. (5) Social security number
       6. (6) Tax identification number
       7. (7) Driver's license number
       8. (8) State of party's driver's license
       9. (9) Vehicle license plate number
       10. (10) Vehicle license plate state
       11. (11) Vehicle identification number
       12. (12) Other names or identifiers used by the party
       13. (13) Claim of injury indicator

   05

A referral of an act of suspected insurance fraud to the Fraud Division shall be legible and on a form as directed by the Department and contain the information and data to the extent applicable, as provided in the following:

Note: Authority cited: Sections 1872.4, 1874.2, 1875.24, 1877.3, 1879.5 and 1879.6, Insurance Code; Calfarm Ins. Co. v. Deukmejian (1989) 48 Cal.3d. 805, 824, 258 Cal. Rptr. 161, 771 P.2d 1247; Credit Ins. Gen. Agents Assn. v. Payne (1976) 16 Cal.3d 651, 656, 128 Cal. Rptr. 881, 547 P.2d 993; and Garris v. Carpenter (1939) 33 Cal. App. 2d. 649, 653, 92 P.2d 688. Reference: Sections 1875.20, 1875.21, 1875.24, 1877.3, 1879.5, 12921(a) and 12926, Insurance Code.

History

1. New section filed 9-4-2003 as an emergency; operative 9-4-2003 (Register 2003, No. 36). A Certificate of Compliance must be transmitted to OAL by 1-2-2004 or emergency language will be repealed by operation of law on the following day.

2. New section refiled 1-2-2004 as an emergency; operative 1-3-2004. (Register 2004, No. 1). A Certificate of Compliance must be transmitted to OAL by 5-3-2004 or emergency language will be repealed by operation of law on the following day.

3. New section refiled 5-4-2004 as an emergency; operative 5-4-2004 (Register 2004, No. 19). A Certificate of Compliance must be transmitted to OAL by 9-1-2004 or emergency language will be repealed by operation of law on the following day.

4. Editorial correction of History 3 (Register 2004, No. 36).

5. New section refiled 9-1-2004 as an emergency; operative 9-1-2004 (Register 2004, No. 36). A Certificate of Compliance must be transmitted to OAL by 12-30-2004 or emergency language will be repealed by operation of law on the following day.

6. New section refiled 12-28-2004 as an emergency; operative 12-30-2004 (Register 2004, No. 53). A Certificate of Compliance must be transmitted to OAL by 4-29-2005 or emergency language will be repealed by operation of law on the following day.

7. New section refiled 4-29-2005 as an emergency; operative 4-29-2005 (Register 2005, No. 17). A Certificate of Compliance must be transmitted to OAL by 8-29-2005 or emergency language will be repealed by operation of law on the following day.

8. Certificate of Compliance as 4-29-2005 order, including repealer and new section, transmitted to OAL 8-26-2005 and filed 10-7-2005 (Register 2005, No. 40).

9. Amendment filed 7-30-2020; operative 10-1-2020 (Register 2020, No. 31).