Commonwealth of Pennsylvania
Office of the Bucks County District Attorney
Private Citizen Referral Form Instructions
This Private Citizen Referral Form is to be used to report someone you suspect is committing insurance fraud. There are several different types of insurance fraud; the most common involves a false statement made in connection with a claim. The basic elements of the most common type of insurance fraud are as follows:
- A person makes a statement in support of an insurance claim;
- The statement contains false, incomplete, or misleading information;
- The information is material (The term "material" means that the information is essential, that it has a logical connection to the facts and that knowledge of that information would affect a person's view of the situation); and
- The statement is made with the intent to defraud an insurer.
Please fill out each section as thoroughly as possible.
Referring Private Citizen Information
Contact information is not mandatory, however we are requesting the name and contact information of the person submitting the referral.
If referring anonymously, please check appropriate box and continue to the Subject information.
If you choose to provide contact information you will receive a confirmation letter stating that our office has received your referral and other follow-up correspondence letting you know what action we have taken on your referral.
Provide the name of the person and/or company you are alleging has committed the insurance fraud. Please provide all available information on the Subject.
*If there are additional Subjects involved, please note this in the Summary.
If this information is available, please include it in this section.
Providing thorough information in this section yields a more complete investigation.
Please provide a summary of your Insurance Fraud complaint. Provide all information that is available to support your allegation.
Clarity and thoroughness in this section are very important for our office's initial review process.
Private Citizen Referral Form
Forms can be filled out and submitted online; or, you can fill it out online, print it and mail it with all other applicable material to:
Gregg Shore, Esq.
Program Director, Insurance Fraud
Bucks County District Attorneys' Office
100 North Main Street, 2nd Floor
Doylestown, PA 18901
Office of the District Attorney
Bucks County Justice Center
100 N. Main Street
Doylestown, PA 18901