Table of Contents 3 Reporting Requirements 4 Instructions for Completing Form FD-1: 9 Suspected Fraudulent Claim Referral 9 SECTION I. Reporting Party Information 9 SECTION II. Loss/Injury Information 9 SECTION III. Suspected Fraudulent Claim Activity 10 SECTION IV. Reports to Other Agencies 11 SECTION V. Contact Information 11 SECTION VI. Insured/Employer Information (Party A) 11 SECTION VII. Other Parties to the Loss/Injury (Additional Parties) Page 2-3 12 APPENDIX A. Reporting Requirements & 13 APPENDIX B. Code Listing 14 APPENDIX C. Suspected Fraud Type Code Definitions 16 APPENDIX D. Form FD-1 Suspected Fraudulent Claim Referral 19
Table of Contents 3 Reporting Requirements 4 Instructions for Completing Form FD-1: 9 Suspected Fraudulent Claim Referral 9 SECTION I. Reporting Party Information 9 SECTION II. Loss/Injury Information 9 SECTION III. Suspected Fraudulent Claim Activity 10 SECTION IV. Reports to Other Agencies 11 SECTION V. Contact Information 11 SECTION VI. Insured/Employer Information (Party A) 11 SECTION VII. Other Parties to the Loss/Injury (Additional Parties) Page 2-3 12 APPENDIX A. Reporting Requirements & 13 APPENDIX B. Code Listing 14 APPENDIX C. Suspected Fraud Type Code Definitions 16 APPENDIX D. Form FD-1 Suspected Fraudulent Claim Referral 19