Ohio Department of Insurance Online Fraud Complaint Form

Please enter your first name and last name and/or check the box that you wish to remain anonymous! Captcha is also required!

* indicates a required field

Contact Information

First Name

Middle

Last Name

Address Line 1:

Address Line 2:

City:

State: Zip/Postal Code:

Email Address:

Phone Number:

Check This Box If You Would Like To Remain Anonymous

Check This Box If You Are Reporting Suspected Fraud On Behalf Of An Insurance Company

Company Name:

NAIC Company Code:

Contact Information

Change

Uppercase Only

Subject Information

Subject is

A person

A business or organization

Is the subject possibly considered violent? Yes?

First Name

Middle

Last Name

Birth date

Age

Organization Name:

Address Line 1:

Address Line 2:

City:

State: Zip/Postal Code:

Email Address:

Phone Number:

Vehicle Information:

Model Year	Make	Model	VIN	License Plate	License Plate State

If you have more than one subject to report, click this button after you have finished the entry for the previous subject.
Entered Subjects:

Subject(s) Information:

Insurance/Claims Information

ALLEGATION Claims

No claims found.


					Loss Amount:	Fraudulent Amount:

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Claim Summary:

Type the name of the insurance company in the field below and select the proper company once its name appears. If a company name does not appear, or you are unsure as to which company you should select, please provide the name of the company in the complaint description section.

Company Name:

NAIC Code:

Policy Number:

Insurance Type:

Claim #:

Claim Date: Loss Date:

Approximate Loss Date: Loss Amount: $

Loss Amount Range: $

Reserve Amount: $

Billed Amount: $

Fraud Identified: Fraudulent Amount: $

Address

Address Type:

Street:

Street 2:

City:

State: Zip Code:

Other Address Explanation:

Medical

Service Description:

Procedure Type Code:

Procedure Code:

Begin Date:

End Date:

Claim Status

Claim Status:

Pending Civil Litigation:

Settlement Amount: $

Settlement Date:

Paid Out Amount: $

Paid Out Date:

Insurance/Claims Information:

Complaint Description

Note: When entering your complaint, please provide as much detail as possible so the Department can clearly assess the situation represented.

Complaint Description: *

Complaint Description:

Supporting Documents (OPTIONAL)

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Most image, document, audio and video file types are supported. Click here for a full list.

The following file types may be uploaded as attachments:

Document Files	Excel Files	Audio Files	Image/ Video Files
DOC	CSV	MP3	DIVX
DOCX	DIF	MPEG	FLV
HTML	XLS	WAV	MKV
HTM	XLSX	WMA	MOV
PDF	XLX		MPEG
RTF	XML		WMV
TXT	XPX		XVID
XPS

Click here to choose a file to upload.

No documents found.

Supporting Documents:

Submit Complaint

To submit your complaint and supporting documentation to the ODI Fraud Unit, please click the button below:

Version: Release-39