Report Fraud - Formstack

Report Insurance Fraud

Name of Person/Company Suspected of Fraud

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Phone

Date of Birth

Name of RLI Entity/Insurance Company that is the Target/Victim of Suspected Fraud

Claim Number

Policy Number

Brief Description of Suspected Fraud

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

Your Email

Your Address

Address Line 1

Address Line 2

City

State

ZIP Code

Your Phone

May we contact you with additional questions or to discus further?

Yes No