NMPRC
 

www.stopfraud.org>>NM Insurance Fraud Report

Liability of the Reporting Person

PLEASE NOTE: NMSA 1978, 59A-16C-7 (1998) (The New Mexico Insurance Fraud Act) states in part that a person shall not be subject to liability by virtue of reporting or furnishing, orally or in writing, information concerning suspected, anticipated or completed insurance fraud acts, except when the person intentionally communicates false information he actually believes to be false, when the report or information is provided to the Superintendent or Insurance Division or agents or employees, any law enforcement agency, anti-fraud unit of an insurer, or any other organization established to detect and prevent insurance fraud.

Instructions

Please complete this form to the best of your ability. When we receive your complaint, we will review the information to determine what action may be taken. There are four potential courses of action. Your case may be:
(1) accepted for additional investigation or prosecution;
(2) referred to another agency;
(3) closed due to the non-prosecutable nature; or
(4) placed into a pending evaluation process until additional information can be obtained from you or other sources.

The more information you can provide, the quicker will be our determination.

  The fields marked with an Valid must be completed if at all possible.

Valid Information About You
  Do you wish to be contacted: Yes No
  If yes, please provide the following information:
required Name:    
Mailing Address:  
Alternative Contact Address:  
City:  
State: Zip:  
Home Phone:
May we contact you here: Yes No
 
Work Phone:
May we contact you here: Yes No
 
requiredEmail Address:
May we contact you here: Yes No
(If you would like for us to be able to contact you by email please edit the noemail@noemail.com  and insert your valid email address in the required email address field. Thank you)
 
 
Valid Insurance Company Reporting [This section for insurance professional’s use only]
  Name:
  Company Represented:
Valid             Reporting Only pursuant to &59A-16C-6 NMSA 1988
Valid              CLAIM NO.
  Mailing Address:
  Alternative Contact Address:
  City: State: Zip:
  Work Phone:
 
Valid Insurance Fraud Information
Valid 1. Date:
                 (approximate day, month, and year(s))
Valid 2. Location:
                      (city, county, state, or reservation)
Valid 3. Estimated Amount:
  4. Status of fraud completed suspected anticipated
  5. Nature of wrongdoing/type of fraud:
  6. Role of Suspect: Insurance Carrier
Insurance Broker/Agent
Insured
Claimant
Medical Provider
Legal Provider
Other:
          
Valid 7. Please state why you believe this incident constitutes a criminal offense; include dates of your discovery, and details of how the suspect knew that actions taken were criminal and not an accident.
 
Valid Suspect Information
Valid 1. Full Name:
Valid 2. Male Female    Valid3. DOB:       Valid SSN:
  4. Complete Address:
  5. Telephone Numbers:
  6. Driver's License No. :     License Plate No:
  7. VIN No:
     
  8. Professional License No:
  9. Other Identification Factors (including physical):
Valid List of Witnesses
  Please provide all (1) witness names; (2) addresses; (3) telephone numbers; (4) all other means of locating them; and (5) their role in this incident.
 
Valid Status of Your Case
  1. Have you reported this incident to any other organization? No Yes
  If yes, check which ones apply: Dept of Insurance/Consumer Relations
District Attorney
Attorney General
other State Fraud Unit
Police Dept
Index
NAIC
NICB - NIBC number:
Other:
  Note the state, county and city of where this was reported:
  2. Was there or is there any pending court action regarding the suspect in this matter?
No Yes         pending resolved
  If yes, provide the following information: Civil Criminal      
Ct. No
.   Ct. Name
 
  County and State:
  List Parties to the Case:
 
Valid Evidence (if attachments are too large, they will stop the form submission, if you get an 'error, failed to send mail' or your form does not submit, please try removing the attachments and then try to submit. You may send the attachments to IFB by email or fax once they have received your submission)
 
  Documents: (Please identify (in the blanks provided) what they are, how they were created, what they prove, where is the original, and in whose possession; include documents such as a policy, the declarations sheet, police reports, checks, application, letters, etc.)
  #1
#2
  Photographs: (Please identify what the photo shows, when the photo was taken, and where the item in the photograph is located and who has it)
  #3
#4
  Other evidence:
#5
 
 

The Fraud Bureau will strive to maintain the confidentiality of this report within the boundaries of law; however, by submitting this form, I understand that all information given herein may become public record at some time in the future because of court order or other legal requirements.