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Row Officers

Commonwealth of Pennsylvania
Office of the Bucks County District Attorney

Insurance Fraud

Insurance Company Referral Form Instructions 

Please fill out each section of the Insurance Company Referral Form as thoroughly as possible.

Referring Agency Information

Provide ALL CONTACT INFORMATION including: your name, your company name, full street address, your e-mail address and a telephone number where you can be reached.

In order to make the referral process as efficient as possible, all of the above information is needed each time you submit a referral.

If you provide a copy of your complete file, including audio copies of all recorded statements, please make sure you note that on the summary or we will follow up with a letter requesting the same.

Additionally, after our initial review of your referral, we often have a number of follow-up questions and may need to contact you for additional information and clarification. Please provide us with a telephone number where we can quickly and easily contact you. Please do not give us a telephone number designed for claim reporting or contact numbers where we will have to endure a lengthy telephone menu to reach you. The more difficult it is to contact you, the longer the review process will take.

Subject Information

Provide the name of the person or persons you are alleging have committed insurance fraud. If there is more than one Subject please provide their information in the Summary. Please provide all available information on the Subject(s). The more detail you provide, the more efficient and thorough we can be on our initial review.

Referral Status

Be sure to answer these questions. Knowing if you have referred this matter to another agency and why you have sent the referral to our office will facilitate the review process.

Location (Counties and/or States)

Knowing the location where each of the following incidents occurred assists us in determining not only the jurisdiction of the case, but also which regional office is best suited to investigate and prosecute the matter.

DO NOT provide DATES in this section.

Indicate COUNTIES if within Pennsylvania and/or STATES if outside of Pennsylvania:

  • Location where the incident occurred. This is the location where the incident occurred that gave rise to a claim being filed.
    • For example, in an auto accident claim, the place where the incident occurred is the location (county or state) where the accident occurred; or in a claim for home repairs, the place where the incident occurred is where the home is located.
  • Location where the claim was received. This is likely to be where the insurance company is located, your claim processing center is located or possibly the business location of the insurance agent.
  • Location where the false statement was made. This is where the subject  is located at the time he made the false statement.
    • For example, if a recorded statement or EUO contains the false statement then note here the physical location of the subject at the time of the recorded statement or EUO. If the false statement is made in submitting a claim form or in the submission of documents supporting a claim. then note here the location where the documents were sent from, such as the subject's home or business. If you don't know the location of the false statement, simply indicate, "not known" on the form.
  • Location where insurance payment was issued. This is the county where the insurance check was issued and mailed from. 
  • Location where insurance payment was sent. This is usually the address where the insurance check was mailed to.

Claim Information

Fill out this section with ALL available information. The information that you provide in this section will increase the efficiency of the review process. If additional Companies are involved, please include their information in the Summary.

Fraud Allegation/Summary

Provide a summary of the essential facts of the case and the specific fraudulent conduct alleged. This part of the referral is critical to our review process. Please take the time to carefully explain your case to us in a logical and coherent manner. Generally, the best approach is to provide us with a chronological outline or narrative of the claims process and your investigation.

Remember, the basic elements of insurance fraud are as follows:

  1. A person makes a statement in support of an insurance claim; 
  2. The statement contains false, incomplete, or misleading information;
  3. The information is material; and
  4. The statement is made with the intent to defraud an insurer.

When writing your summary make sure you clearly identify what you believe to be the false statement.

Your referral should include:

  • The date(s) of the false statement(s);
  • The person(s) to whom the false information was relayed; and
  • How it was recorded by your company.

Please Remember:

The person reviewing the referral is not familiar with the file. On the other hand, it is likely you have been working on the file for a significant amount of time and are very familiar with all the details. Under these circumstances it is sometimes difficult to remember to include all the necessary background on a case, rather than just your conclusion. However, the background details are critical to our review.

Provide ALL relevant information. This should include all significant facts pertaining to the claim, including information that supports your allegation and information that may not support your allegation.

While it is understandable that you will want to present your case in the light most favorable to your position, it is nevertheless crucial that you provide all relevant information.

Clearly state how the false statement is material or important to the claim. 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 facts. Not all false statements or lies are material. For example, the claimant makes a false statement to an insurer, but the claim would have been paid regardless; here the false statement may not have been material. You should be able to distinguish what would have occurred  if the truth had been known or conversely, what would have occurred if the false statement had not been made to the insurance company.

Do not use insurance abbreviations or codes. Write your summary in plain English.

Do not refer to people as "claimant" or "insured." Instead, simply identify by name who you insure and the names of all other parties. Then continue to refer to each person by their surnames.

Do not cut and paste claim notes or log notes. These notes merely document a specific moment in time. Reading them  out of context is often confusing.

Insurance Company 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:

Marc Furber, 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 
Phone: 215-348-6344 
Fax: 215-348-6299

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