Sec. 86.5. Reports of fraudulent acts

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 Criminal Investigations Unit. Reports shall be submitted on the prescribed reporting form issued by the Criminal Investigations Unit 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

DEPARTMENT OF FINANCIAL SERVICES

CRIMINAL INVESTIGATIONS UNIT REPORTING FORM

 

DATE

 

To:

State of New York

 

(1) Information furnished by:

 

Department of Financial Services

 

Company

 

Criminal Investigations Unit

 

Name:

 

One State Street

 

____________

New York, NY 10004

 

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.^* 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. 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.

 

 

 

10. 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 __

11. 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.

Notation

*

Major insurance fraud or corruption is defined as: (1) a scheme that 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 that involves less than $100,000, this form may still be submitted or a referral may be made by letter.