REPORT AN INDIVIDUAL

To ensure that your allegation can be processed and/or investigated thoroughly, please provide as much information as possible on the allegation using the questions below:

Who was involved?
What are the details of the fraudulent activity?
When did the fraud take place?
Where did the fraud take place?

Individual Fraud Report Form

Last 4 Digits of Individual’s Social Security Number

Individual’s First Name *

Individual’s Last Name *

Agency Employed

Please describe in detail the fraud allegation (see items to consider above) *

Note: You have the option to submit this allegation anonymously. However, this may limit our ability to act on the allegation, so any contact information would be valuable.

Your Contact Information

May we contact you for any follow up information? If selecting “yes,” please be sure all fields below are completed with your contact information. *

Your First Name

Your Last Name

Phone Number (Including Area Code)

Email Address

If you have any other questions, please call 1.844.413.7283. Thank you!

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REPORT AN INDIVIDUAL

Individual Fraud Report Form

Your Contact Information

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