New Jersey Administrative Code › Title 13 - LAW AND PUBLIC SAFETY › Chapter 88 - OFFICE OF INSURANCE FRAUD PROSECUTOR › Appendix - APPENDIX

Current through Register Vol. 56, No. 14, July 15, 2024
STATE OF NEW JERSEY
OFFICE OF THE INSURANCE FRAUD PROSECUTOR
INSURANCE FRAUD REPORTING REWARD APPLICATION
APPLICANT INFORMATION
Name: ___________________________________________________________________
Address: ___________________________________________________________________
Number and Street Apt. No.
___________________________________________________________________
City State Zip Code
Phone: (H) __________________________ (W) __________________________
Email: _______________________________
Do you wish to keep your identity confidential? Yes ________ No ________
Nondisclosure of your identity is subject to any statute, Rule of Court or
judicial decision which may require divulgence of such identity to certain
parties including, in certain circumstances, criminal defendants.
DEADLINE: A reward application must be filed within 30 days of the date on
which the applicant initially provided the information to OIFP.
INFORMATION PROVIDED
(You may attach additional sheets if needed)
Date(s) of Incident: _______________________________________________________
Location: __________________________________________________________________
Detailed Description of Incident: __________________________________________
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Suspect(s): Name _________________________________________________
Address _________________________________________________
_________________________________________________
Witness(es): Name _________________________________________________
Address _________________________________________________
I hereby certify that the information provided above is true and accurate.
I am aware that if any of the foregoing information is willfully false I am
subject to punishment.
____________________________________ ____________________________________
Date Signature of Applicant (sign only in
the presence of a Notary Public)
____________________________________ ____________________________________
Notary Public Date
Notary Seal: