N.Y. Comp. Codes R. & Regs. tit. 11, § 86.5
(5) Name, title, address and telephone number of individual in your company who can provide detailed information:
Name Title Address Tel.#
(6) Have you reported this transaction to any other law enforcement agency?
If yes, furnish name of agency, address, person contacted, date of report and telephone #.
Signed:
Title:
IFB-1
UNITED STATES DEPARTMENT OF JUSTICE
INSURANCE RELATED CRIMINAL REFERRAL FORM
To Be Used for Criminal Referrals in Suspected Cases of Major Insurance Fraud or Corruption.* Please provide as much of the requested information as possible, but if any information is unavailable leave the answer blank.
1. Name and Location of Insurance Company/Agency/Entity
Name
Location street city state zip
Location of Suspected Offense:
3. Approximate date and dollar amount of loss due to suspected violation.
Date Amount Month Year
4. Summary characterization of the suspected violation. Check appropriate item(s).
__Defalcation/embezzlement
__ False Statement by insurance company (e.g. assets/liabilities; ownership; reserves)
__ Misuse of Position or Self Dealing; other abuses by insurance company insiders
__Check Kiting
__Bank Fraud
__ Bank Secrecy Act/Money Laundering
__Employee Benefit Plans (ERISA)
__METS & MEWAS
__Reinsurance
__Tax Violations
__Public Corruption/Bribery
__Securities Fraud
__Other (Describe)
__
__
c. Date of Birth________ Social Security No. ______
(if known) mo/day/yr (if known)
d. Relationship to the insurance entity. Check all applicable item(s)
__Officer
__Director
__Employee
__Accountant
__Consultant
__Third Party Administrator
__Managing General Agent
__Agent/Broker
__Appraiser
__Lawyer
__ Employee Benefit Plan Service Provider
__Stockholder
__Policyholder
__Other (Specify)
__ ________
__ ________
e. Is person still affiliated with the insurance entity?
__yes __no If no, __Terminated__Resigned
FORM OMB-1105-0054
f. Is person affiliated with any other insurance entities?
If yes, please identify
7. Witnesses If known, list any witnesses who might have information about the suspected violation and describe their position or employment. Indicate if they have been interviewed. (Use continuation sheet if necessary.)
Name Position Address Tele. Interviewed
Yes No
a. Send one copy to the office of the Federal Bureau of Investigation (FBI) nearest to where the suspected offense took place.
FBI office to which form was sent:
city/state
b. If the allegations are false claims or mail fraud, please send one copy to the Postal Inspection Service nearest to where the suspected offense took place. Postal Inspection Service office to which form was sent:
city/state
1. Employee Benefit Plans (ERISA); Multiple Employer Trusts or Welfare arrangements.
Send to: Office of Labor Racketeering U.S. Department of Labor Room S-5012 200 Constitution Avenue Washington, DC 20210 Referral sent Yes __ No __ Pension & Welfare Benefits Administration Enforcement Section U.S. Department of Labor Room N - 5702 200 Constitution Avenue Washington, DC 20210 Referral sent Yes __ No __
2. Tax Violations; Bank Secrecy Act/Money Laundering
Send to: Internal Revenue Service Criminal Investigation Division 1111 Constitution Avenue Room 2143 Washington, DC 20224 Attn: Director of Operations Referral sent Yes __No __
11. Person to contact for further information about referral Name Position Organization Phone No. Date of referral
Public reporting for this collection of information is estimated to average one hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing this burden to Fraud Section, Criminal Division, U.S. Department of Justice, Washington, DC 20530; and to The Office of Management and Budget, Washington, DC 20503.
Any person licensed pursuant to the provisions of the Insurance Law who determines that an insurance transaction or purported insurance transaction appears to be fraudulent or suspect shall submit a report thereon to the Criminal Investigations Unit. Reports shall be submitted on the prescribed reporting form issued by the Criminal Investigations Unit or upon any other form approved by order of the superintendent. Reporting may also be done by means of any electronic medium or system approved by order of the superintendent.
STATE OF NEW YORK
DEPARTMENT OF FINANCIAL SERVICES
CRIMINAL INVESTIGATIONS UNIT REPORTING FORM
DATE
To:
State of New York (1) Information furnished by:
Department of Financial Services Company
Criminal Investigations Unit Name:
One State Street ____________
New York, NY 10004 Address:
____________
____________
NAIC #
____________
PLEASE PRINT/TYPE INFORMATION