Confidential Fraud Report

All information provided in this form will be treated with confidence.

You do not need to fill in all sections of this form; however please provide sufficient information to enable us to look into the matter.

Please provide your details:

Your name *

Phone number*

Email address*

Postal address*

Do you agree for a team member to contact you if further information is required?*

Yes

Make a report

Please enter any information you may know about the person or company you suspect of commiting fraud

Surname or Company Name

First name

Any aliases that the person might have (or maiden name/ married name)

Gender

Male

Female

Date of birth or estimated age

Address

Phone number(s)

Date or approximate date of the insurance claim

How do you know this person/company?

Name of the insurance company (if known)

Details of the suspected fraud

Please include a summary of the incident, location and details associated with the claim or policy. Please also provide any other information you feel may assist us in identifying the claim or claimant.

If we find that your information relates to another insurer; you give us your permission to pass on this information to the other insurer or the Insurance Council of NZ.

Yes, I give my permission.

Marine insurance

Marine claims

Confidential Fraud Report