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2. First Name:*
3. Last Name:*
5. Your Address:*
6. Name of Your Organization: (if applicable)*
8. Address Line 2:
9. Your Email Address:*
11. City, State:*
12. Your Telephone Number:*
14. Zip Code:*
18. What is the false / misrepresentation / potential fraud you believe was committed and by whom? Please attach copies of any supporting documentation to this complaint.*
20. Supporting Documentation
22. How do you know it is a false statement / misrepresentation / potential fraud and what evidence supports your conclusion?*
24. Supporting Documentation
26. Why does the false statement / misrepresentation / potential fraud matter?*
28. Did a licensed professional participate?*

    1. Yes

    1. No
30. If representing a business / organization, what was the amount claimed?*
32. If representing a business / organization, what was the amount paid?*
34. Date of Loss:*
    Date of Loss:
36. Individuals Involved – Suspects:*

    If available, please include names, addresses, and telephone numbers of any parties you believe are involved in the false statement / misrepresentation / potential fraud.

38. Individuals Involved – Witnesses:*

    If available, please include names, addresses, and telephone numbers of any parties you believe are involved in the false statement / misrepresentation / potential fraud.

40. Other Agencies or Individuals Contacted About This Matter:*

42. If you would rather print and mail this form to our office, with all supporting documentation, please click on this link, or the one below, to download a PDF version of this form.
    
    Please only submit this once - online using the Submit button OR by mail.

    
    

    You can mail a printed copy of this form (and all documentation) to:

    South Carolina Department of Insurance

    Insurance Fraud Division

    P.O. Box 100105

    Columbia, SC 29202

    Or attach it in an email and send it to FraudDivision@doi.sc.gov.

    Download PDF Version

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44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit

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