Report Insurance Fraud

Please complete this form to the extent possible.

Name of person/company suspected of fraud:
Address:
City:	State: Zip Code:
Telephone:
If person – date of birth:
Name of RLI entity/insurance company that is the target/victim of suspected fraud:
Claim number, if known:
Policy number, if known:
Brief description of suspected fraud:
Although we encourage you to provide us with your contact information, that is not required to complete and file this report. May we contact you with additional questions or to discuss further:  Yes  No Your contact information will remain anonymous throughout our investigation.
Contact name:
Contact address:
Contact city:	State: Zip Code:
Contact telephone:
	Type case sensitive characters shown to verify.