New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter IV - Financial Condition Of Insurer and Reports to Superintendent › Subchapter A - Rules of General Application › Part 86 - Reports Of Suspected Insurance Frauds To Insurance Frauds Bureau; Required Warning Statements › Section 86.5 - Reports of fraudulent acts

Current through Register Vol. 46, No. 28, July 10, 2024
Any person licensed pursuant to the provisions of the
					 Insurance Law who determines that an insurance transaction or purported
					 insurance transaction appears to be fraudulent or suspect shall submit a report
					 thereon to the Insurance Frauds Bureau. Reports shall be submitted on the
					 prescribed reporting form issued by the Insurance Frauds Bureau or upon any
					 other form approved by order of the superintendent. Reporting may also be done
					 by means of any electronic medium or system approved by order of the
					 superintendent.
STATE OF NEW YORK
INSURANCE DEPARTMENT
INSURANCE FRAUDS BUREAU REPORTING FORM
DATE ____________
To:
State of New York
(1)
				  Information furnished by:
Insurance Department Company
Frauds Bureau Name:
60 West Broadway ________
New York, NY 10013 Address:
________
________
NAIC #
________
PLEASE PRINT/TYPE INFORMATION
____________
(2)
				  Brief statement of suspect transaction and dollar amount of claim:
____________
(3) Identify parties to suspect transaction
				  (name, address and relation to transaction):
____________
(4) Identify your policy, claim or reference
				  number under which the above transaction is recorded: ____________
____________
(5) Name, title, address and telephone number
				  of individual in your company who can provide detailed information:
Name Title Address Tel.#
____________
(6) Have you reported this transaction to any
				  other law enforcement agency? ____________
If yes, furnish name of agency, address, person contacted,
					 date of report and telephone #.
____________
Signed: ____________
Title: ____________
IFB-1
UNITED STATES DEPARTMENT OF JUSTICE
INSURANCE RELATED CRIMINAL REFERRAL FORM
To Be Used for Criminal Referrals in Suspected Cases of
					 Major Insurance Fraud or Corruption.[FN*] Please provide as much of the
					 requested information as possible, but if any information is unavailable leave
					 the answer blank.
1. Name and Location
				  of Insurance Company/Agency/Entity
Name ____________
Location
_________
street
______
city
state
zip
Location of Suspected Offense:
____________
2. Asset Size of Insurance
				  Company/Agency/Entity ____________
3. Approximate date and dollar amount of loss
				  due to suspected violation.
Date ____________ Amount ____________
Month Year
4. Summary characterization of the suspected
				  violation. Check appropriate item(s).
________Defalcation/embezzlement
________False Statement by insurance company (e.g.
					 assets/liabilities; ownership; reserves)
________Misuse of Position or Self Dealing; other abuses by
					 insurance company insiders
________Check Kiting
________Bank Fraud
________Bank Secrecy Act/Money Laundering
________Employee Benefit Plans (ERISA)
________METS & MEWAS
________Reinsurance
________Tax Violations
________Public Corruption/Bribery
________Securities Fraud
________Other (Describe)
________ ____________
________ ____________
5. Person(s) Suspected of Criminal Violation
				  (If more than one, use Continuation Sheet.)
a. Name
______
first
______
middle
last
b. Address
_______
street
city
state
zip
c.
				  Date of Birth________ Social Security No. ________
(if known) mo/day/yr (if known)
d. Relationship to the insurance entity.
				  Check all applicable item(s)
________Officer
________Director
________Employee
________Accountant
________Consultant
________Third Party Administrator
________Managing General Agent
________Agent/Broker
________Appraiser
________Lawyer
________Employee Benefit Plan Service Provider
________Stockholder
________Policyholder
________Other (Specify)
________ ________
________ ________
e. Is person still affiliated with the
				  insurance entity?
________yes ________no If no,
					 ________Terminated________Resigned
FORM OMB-1105-0054
EXP.AUG.95
f. Is person affiliated with any other
				  insurance entities?
If yes, please identify____________
____________
6. Explanation/Description of Suspect
				  Activity (You may use a separate sheet)
Give an account of the suspected criminal activity.
____________
____________
____________
____________
____________
____________
____________
____________
____________
7. Witnesses
If known, list any witnesses who might have information
					 about the suspected violation and describe their position or employment.
					 Indicate if they have been interviewed. (Use continuation sheet if
					 necessary.)
Name Position Address Tele. Interviewed
Yes No
(1)
				  ________ ________ ________ ________
(2) ________ ________ ________ ____________
8. Is this matter the
				  subject of any civil law suit or regulatory action including liquidation or
				  insolvency proceedings? If so, please describe. ____________
9. Is this matter the subject of any civil
				  law suit or regulatory action including liquidation or insolvency proceedings?
				  If so, please describe.
____________
____________
____________
10. Has a referral or complaint been made
				  about this or a related matter or individual to a state insurance regulatory
				  agency, law enforcement, a U.S. Attorney's Office, State Attorney General's
				  Office or other prosecutor's office? If so, please describe.
____________
____________
____________
11. Distribution Information
a. Send one copy to the office of the Federal
				  Bureau of Investigation (FBI) nearest to where the suspected offense took
				  place.
FBI office to which form was sent:
______________
city/state
b. If the allegations are false claims or
				  mail fraud, please send one copy to the Postal Inspection Service nearest to
				  where the suspected offense took place.
Postal Inspection Service office to which form was
					 sent:
______________
city/state
c. Send one copy to: U.S. Department of
				  Justice, Criminal Division, Fraud Section, 10th & Pennsylvania NW,
				  Washington, DC 20530, Attention: Karen Morrissette, Deputy Chief.
d. In addition, if the allegations in this
				  referral involve any of the categories as listed below, please send a copy to
				  the corresponding agency listed below and indicate that the referral was sent.
1. Employee Benefit Plans (ERISA); Multiple
				  Employer Trusts or Welfare arrangements.
Send to: Office of Labor Racketeering
U. S. Department of Labor
Room S-5012
200 Constitution Avenue
Washington, DC 20210
Referral sent Yes ________ No ________
Pension & Welfare Benefits
Administration
Enforcement Section
U. S. Department of Labor
Room N - 5702
200 Constitution Avenue
Washington, DC 20210
Referral sent Yes ________ No ________
2. Tax Violations; Bank Secrecy Act/Money
				  Laundering
Send to: Internal Revenue Service
Criminal Investigation Division
1111 Constitution Avenue
Room 2143
Washington, DC 20224
Attn: Director of Operations
Referral sent Yes ________No ________
12. Person to contact
				  for further information about referral
Name ____________
Position ____________
Organization ____________
Phone No. ____________
Date of referral ____________
Public reporting for this collection of information is
					 estimated to average one hour per response, including the time for reviewing
					 instructions, searching existing data sources, gathering and maintaining the
					 data needed, and completing and reviewing the collection of information. Send
					 comments regarding this burden estimate or any other aspects of this collection
					 of information, including suggestions for reducing this burden to Fraud
					 Section, Criminal Division, U.S. Department of Justice, Washington, DC 20530;
					 and to The Office of Management and Budget, Washington, DC 20503.
[FN*] Major insurance fraud or corruption is defined as:
(1) a scheme which resulted in a loss
				  to the state, company, policyholders, a multiple employer trust (MET), a
				  multiple employer welfare arrangement (MEWA), or participants in METS or MEWAs
				  of more than $100,000 or a gain to the perpetrator of more than $100,000; or
(2) insurance-related public
				  corruption, such as bribery of a public official, regardless of the amount.
				  Please exclude all arson cases or matters. In the event a fraud is uncovered
				  which involves less than $100,000, this form may still be submitted or a
				  referral may be made by letter.