PURPOSE: This rule sets forth the forms to be used in reporting fraudulent insurance acts to the Missouri Depart- ,’ ment of Insurance under sections 375.991-375.994, RSMo. (1) The Fraud Investigation Report (Insurer) form set forth as Exhibit 1 of this rule shall be used by any insurer reporting an allegation of a fraudulent insurance claim to the department. This form also may be used by an insurer seeking the department’s assistance in the investigation and prosecution alleged fraudulent insurance claims and other types of fraudulent insurance act+ (2) The Fraud Investigation Report (Consumer) form set forth as Exhibit 2 of this rule shall be used by any noninsurer for reporting , ., a fraudulent insurance act to the department. Auth: sections 374.045, RSMo (1986) and 375.991, 375.992, 375.993 and 375.994, RSMo (Cum. Supp. 1990).” Original rule filed Sept. 15,1992, effectiuehne 7,1993. *Original authority: 374.045, RSMo (1967) and 375.991-375.994, RSMo (1990).

Judith K. Moriarty (4/26/93) CODEOF STATE REGULATIONS 3

20CSRlOO-34NSURANCE

STATE OF MISSOURI DEPARTMENT FRAUD INVESTIGATION REPORT (INSURER)

INSURER REPORTING 0 Claim Reportlnq Only should check the adjacent 0 Assistance Requested, RSMo, and who a/so seek check the adjacent box. provide 2 of this Report. 0 Assistance Requested. insurance act other this Report @ follow Send this form. along with any attachments OF INSURANCE

REQUIREMENTS Insurers who seek only to report a suspected box and provide the mformation Clam: Insurers who seek the Department’s assistance the information Non-Claim: insurers requesting than a fraudulent insurance the instructions which appear on the SIDE 2 of this Report to: Exhibit 1

fraudulent

required on SIDE 1 of this Fraud

to report a suspected in investigating required on SIDE 1 of the Department’s claim should check

Consumer Fraud Unit Department of Insurance P.O. Box 690 insurance fraudulent insurance and prosecuting the suspected thls Report e assistance in lnvestlgatlng the adlacent box, provide Division lOO-Division of Consumer Affairs

CONFIDENTIAL This report and the attached confldentlal to the extent prowded 375.993 of the Rewed

clam in order to satisfv lnvestlgatlon Report. clam in order to satisfy fraudulent follow the instructions and prosecuting the informatlon

(4/26/93)*

documents are under Sect,on

Statutes of Missour$.

section 375 992. RSMo section 375.992, insurance claim should which appear on SIDE a suspected fraudulent required on SIDE 1 of

Judith K. Moriarty Secretary of Sta:e

1. 4. A cover letter on company Fraud Report

3 The request

1. 1. Full name, date of birth, address and social security
2. 2. Full name, date of berth, address and social security
3. 3. Date and location

4 Brief summary

1. 5. If injury doctor.

6 If Clalmant

1. 7. Name and office address of each attorney,
2. 8. Narrative

I , 2 Attachments

1. 1. Copy of Proof of Loss to your company.
2. 2. Copy of Index Bureau Report,
3. 3. Copy of the official
4. 4. Copy of any additional
5. 5. Copy of all statements

6. 6. Copy of coverage

   retain all original

I ’ ‘lease n some cases :hese instances, ‘ile to be forwarded.

Section 375 993.2 RSMo Supp 1991 provides: !:

1. 2. No insurer, civil liability section or required

Judith K. Moriarty stationery must accompany

for investigation should contain

of accident,

of facts relating

involved, list name and address of each doctor

treated in hospital,

statement of reasons why claim

accident

documents

taken. Recorded

analysis.

documents,

it may be necessary an official request

employees or agents of any

for libel or otherwise by the Department

(4/26/93)’ the following

loss or theft.

to the claim. If settled, show amount of settlement

list name of hospital,

date retained, and copies of all demand

is suspected

If property

if applicable

report.

that may indicate

statements must be transcribed,

along with the postmarked

for an investigator in writing will be made by this Department

insurer

by virtue of the of Insurance each case submitted

informatlon:

number, occupation and employer

number, occupation and employer

consulted, records of treatments

date of admIssion. and itemized

to be fraudulent with documentation

involved, submit complete

fraud, such as photographs.

envelopes in which

from the Consumer Fraud Unit to the company’s

or any other person acting without malice, filing of reports or furnishing as a result of the authority 20 CSR 100-3

for investigation, in addition to this Consumer

of the insured

of claimant

and charges submitted by each

charges

letters

description.

they were received, in your claim file.

to have access to the entire file. In claims manager for the entire

shall be subject to

other information requested by this

granted in this section. 20CSRlOO-34NSURANCE

STATE OF MISSOURI DEPARTMENT OF INSURANCE FRAUD INVESTIGATION

1 INSTRUCTIONS

Please complete all items below and enclose investigation of your complaint. Send completed form along with any attachments

OROUP OR CERTlFlC*TE NUMBER

CLNM NUMBER

NATURE OF COMPLAINT GROUP 7 LIFE 0 HEALTH ETAILS OF COMPLAINT (USE BACK IF NECESSARY) Exhibit 2

REPORT (CONSUMER)

copies of any correspondence or other papers which you

Sign and date at the bottom. to: Consumer Fraud Unit Department of Insurance P.O. Box 690 Jefferson City, Missouri 65102-0690 Telephone: (314) 751-2640 Telecommunications Device for the Deaf (TDD) Number:

PLEASE PRINT. TYPE OR WRITE CLEARLY

POLICY OR I.D. NUMSER

AGENT NAME (IF APPLICABLE)

INDIVIDUAL FIRE El AUTO Cl HOMEOWNERS

cl HEALTH

DATE

THlS FORM MAY BE COPIED IF NECESSARY

Division lOO-Division of Consumer Affairs

CONFIDENTIAL This report and the attached documents are confidential to the extent provided under Section 375.993 of the Revised Statutes of Missouri.

feel would help the

1. (314) 526-4536

   EFFECTiVE DATE

   DATE OF LOSS

   WORKERS q gHER ISPECIFY)

0 COMPENSATION

C

(4/26/93)’ Judith K. Moriarty