Insurance Fraud Individual Complaint

STATE OF NEVADA OFFICE OF THE ATTORNEY GENERAL 555 E. Washington Ave., #3900 Las Vegas, NV 89101 Phone: 702-486-3420 Fax: 702-486-3768 www.ag.nv.gov For official use only: Received by: ____________ Date Received: ___________ Complaint Type:___________________ Referred to: IFU MFCU BCP PIU GI WCFU OML MFU [Stamp here] The information you report on this form may be used to help us investigate violations of state laws. When completed, mail or fax your form and supporting documents to the office location listed above. Upon receipt, your complaint will be reviewed by a member of our staff. The length of this process can vary depending on the circumstances and information you provide with your complaint. The Attorney General's Office may contact you if additional information is needed. If you have a claim against the State of Nevada, complete the Tort Claim Form found on our website. INSTRUCTIONS: Please TYPE/PRINT your complaint in dark ink. You must write LEGIBLY. All fields MUST be completed. INSURANCE FRAUD INDIVIDUAL COMPLAINT FORM SECTION 1. COMPLAINANT INFORMATION Your Name: ________________________________________________________________________________________ Last First MI Your Address: ______________________________________________________________________________________ Address Home Cell City Work State Fax Home Cell Work Zip Your Phone Number: ________________________________________________________________________________ Email: ___________________________________________ Call me between 8am-5pm at: Age: Under 18 18-29 30-39 40-49 50-59 60 or older COMPLAINT IS AGAINST Business/Provider Name:_____________________________________________________________________________ Individual/Contact: ___________________________________________________________________________________ Last Address Work Mobile First City Job Title (Example: CEO) State Fax Zip Individual/Business Address: __________________________________________________________________________ Individual/Business Phone: ____________________________________________________________________________ Individual/Business Email: ____________________________________________________________________________ Individual/Business Web Site: __________________________________________________________________________ Complaint Form: Page 1 of 4 Rev: 12/18/13 Facebook:/NVAttorneyGeneral Twitter: @NevadaAG YouTube: /NevadaAG American LegalNet, Inc. www.FormsWorkFlow.com Name and address of other involved persons or persons who can provide additional information: SECTION 2. Did you make any payments to this individual or company? Yes­Continue to Next Question No­Skip to Section 3 How much did the company/individual ask you to pay? ______________________________________________________ Date(s) of payments (mm/dd/yyyy): _____________________________________________________________________ How much did you actually pay? $ ______________ Financed Wire Transfer Yes Money Order No Payment Method: Cashier's Check Cash Credit Card Debit Card Check Other: ________________________ Was a contract signed? If yes, date you signed the contract (mm/dd/yyyy): _____________________ Identify your attempts to resolve the issue(s) with the company, corporation, or organization. Have you contacted another agency for assistance? Yes No If so, which agency? _________________________________________________________________________________ Have you contacted an attorney? Yes No If so, what is the attorney's name, address, and phone number? __________________________________________________________________________________________________ Last Address Is court action pending? Yes No First City Phone State Have you lost a lawsuit in this matter? Yes Zip No __________________________________________________________________________________________________ SECTION 3. Please detail the nature of your complaint against the insurance company, individual or provider listed in Section 1. Include the who, what, where, when, and why of your complaint. (Please include any nicknames or aliases, identifying information such as Social Security number(s), license plate(s), year/make of vehicle(s), etc.). You may use additional sheets if necessary. My complaint is: Complaint Form: Page 2 of 4 Rev: 12/18/13 Facebook:/NVAttorneyGeneral Twitter: @NevadaAG YouTube: /NevadaAG American LegalNet, Inc. www.FormsWorkFlow.com SECTION 4. List and attach photocopies of any relevant documents, agreements, correspondence, or receipts that support your complaint (examples include billing statements, correspondence, receipts, payment information, witnesses, and any other document which explains or supports the matters raised in the complaint). No originals. Copy both sides of any canceled checks that pertain to this complaint. SECTION 5. Sign and date this form. The Attorney General's Office cannot process any unsigned, incomplete, or illegible complaints. I understand that the Attorney General is not my private attorney, but rather represents the public by enforcing laws prohibiting fraudulent, deceptive or unfair business practices. I understand that the Attorney General does not represent private citizens seeking refunds or other legal remedies. I am filing this complaint to notify the Attorney General's Office of the activities of a particular business or individual. I understand that the information contained in this complaint may be used to establish violations of Nevada law in both private and public enforcement actions. In order to resolve your complaint, we may send a copy of this form to the person or firm about whom you are complaining. I authorize the Attorney General's Office to send my complaint and supporting documents to the individual or business identified in this complaint. I also understand that the Attorney General may need to refer my complaint to a more appropriate agency. I certify under penalty of perjury that the information provided on this form is true and correct to the best of my knowledge. ___________________________________________ Signature ______________________ Date (mm/dd/yyyy) ______________________________________________ Print Name SECTION 6. (Optional) The following section is optional and is intended to help our office better serve Nevada consumers. Please check the categories that apply to you. Gender: Male Female Have you previously filed a complaint with our office?: Yes No If yes, enter in the approximate filing date (mm/dd/yyyy) of your original com