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Insurance Crime Application Form

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INSURANCE CRIME APPLICATION FORM

Applicant / Insured Information

Date of birth:

Policy Details Requested

Employee Dishonesty Forgery or Alteration Computer Fraud Funds Transfer Fraud

Policy period requested: From to

Coverage Options (select all that apply)

Employee dishonesty (including loss by theft of company funds by an employee)
Forgery or alteration of negotiable instruments
Computer fraud and hacking losses
Funds transfer fraud (unauthorized transfer instruction)
Burglary, robbery and theft of tangible property
Social engineering / impersonation fraud

Exclusions and Acknowledgments

The applicant acknowledges that requested coverages are subject to policy exclusions, including but not limited to: (a) losses arising from the insured's deliberate dishonest acts committed by an insured or agent with intent to cause loss; (b) war, civil commotion, nuclear hazard, and governmental action; (c) punitive, exemplary or multiple damages except where insurable by law; (d) losses attributable to inventory shortage or bookkeeping errors unless caused by covered criminal acts; and (e) losses resulting from the insured's failure to maintain reasonable internal controls and segregation of duties. Applicant affirms that the information provided is true to the best of applicant's knowledge and that additional specific exclusions may be set forth in any issued policy.

I acknowledge and understand the exclusions described above

Beneficiary / Payee for Recoveries

If recovery payments are to be made to a third party, provide details below. If recovery proceeds are to be credited to the insured, indicate insured name.

Claims and Loss History (Past 5 Years)

Has the applicant sustained any crime-related loss, attempted loss, or filed a claim for such loss in the past five years?

Yes No

Proposed Coverage - Incident Examples and Limits

Provide typical scenarios you seek coverage for and estimated maximum single occurrence exposure.

Documentation Checklist (provide with application)

Please indicate which documents are included with this application. Failure to provide requested documentation may delay underwriting.

Police report (if applicable)
Bank statements and reconciliations
CCTV or electronic evidence
Employee records and access logs
Inventory or asset lists, invoices, receipts

Declarations, Authorizations, and Certifications

The applicant certifies that the statements and particulars supplied in this application are true and complete. The applicant understands that any material misrepresentation, concealment of fact, or omission may be grounds for denial of coverage or rescission of any policy issued on the basis of this application. The applicant authorizes the insurer and its representatives to make inquiries and obtain records, including financial, personnel, law enforcement, and electronic records, as reasonably necessary to evaluate this application and any subsequent claim. The applicant agrees to cooperate with any investigation and to furnish proof of loss, submit to examinations under oath, and assist in preserving and collecting evidence for subrogation.

The applicant understands that coverage, if issued, will be subject to policy terms, conditions, limitations, and exclusions. The applicant grants the insurer full subrogation rights against third parties responsible for loss and agrees to assign recoveries to the insurer to the extent of payments made under the policy.

Fraud Warning and Legal Notice

It is unlawful to knowingly provide false, incomplete, or misleading information for the purpose of obtaining insurance or a benefit. Such acts may constitute insurance fraud and may subject the applicant to civil or criminal penalties, including denial of the claim, rescission of coverage, fines, and imprisonment where applicable by law.

Applicant Name:

Signature:

Date:

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What the Insurance Crime Application Form Is

The Insurance Crime Application Form is a standardized document used by insurers, brokers, and law enforcement to report suspected insurance fraud, submit claims-related investigative requests, or request formal review of potentially fraudulent activity. It collects identifying information about the insured, details of the incident or claim, policy numbers, supporting evidence summaries, and declarations required under penalties of perjury. Organizations use the form to centralize allegations, trigger internal investigations, and, when appropriate, to refer cases to state insurance fraud bureaus or law enforcement for further action.

Why completing the form correctly matters

Accurate, complete Insurance Crime Application Forms improve the speed and quality of fraud assessments, reduce false positives, and protect compliant policyholders by enabling timely investigation and potential recovery of funds.

Why completing the form correctly matters

Who completes and reviews this form

The Insurance Crime Application Form is typically completed by claims adjusters, special investigations units (SIU), underwriters, or third-party investigators when suspected fraud or irregularities arise.

  • Claims professionals and SIU staff responsible for evaluating questionable claims and compiling evidence for internal review or referral.
  • Independent investigators, private examiners, or legal counsel preparing formal reports for insurers or regulators.
  • Regulatory or law enforcement personnel receiving referrals to determine whether statutory investigation or prosecution should follow.

Reviewers should verify identity data, policy details, incident chronology, and attached evidence before routing the completed form to the appropriate internal unit or external agency.

Step-by-step: completing the Insurance Crime Application Form

Follow these sequential steps to ensure a complete, legally defensible submission that supports efficient investigation.

  • 01
    Collect identifiers: Gather insured name, policy number, and claim ID.
  • 02
    Document the incident: Write a clear chronological description with dates and locations.
  • 03
    Attach evidence: Upload photos, invoices, police reports, and statements.
  • 04
    Verify and submit: Confirm accuracy, sign, and forward to SIU or regulator.

Alternate workflow for multi-party cases

Use this grid-style checklist when multiple departments or external partners contribute information.

01

Intake:

Record initial report and assign a claim number.
02

Evidence collection:

Gather documents, secure chain of custody.
03

Internal review:

SIU assesses severity and assigns investigator.
04

External referral:

If warranted, refer to state fraud bureau or law enforcement.
05

Legal review:

Consult counsel for potential recovery or litigation.
06

Closure:

Document outcome and retention instructions.

Routing and processing flow

This outline shows the common routing used after the form is submitted to ensure accountability and auditability.

  • Submission: Form enters the claims system with timestamp.
  • Triage: SIU or triage team evaluates priority.
  • Investigation: Assigned investigator collects further proof.
  • Disposition: Case closed, recovered, or referred externally.

Configuring an online submission workflow

Set these fields when building a digital intake to enforce validations and routing rules.

Field Configuration
Policy Number Required; regex validate length
Date of Incident Required; format MM/DD/YYYY, no future dates
Evidence Attachments Allow PDFs, JPEGs; max 25 MB per upload
Routing Auto-route by claim severity code

Technical and platform considerations for e-submission

Choose a platform that supports secure uploads, audit trails, and conditional fields for investigators.

  • File types: Accept PDF, DOCX, JPEG, PNG
  • Authentication: Email link, SMS code, or stronger MFA
  • Integrations: Connectors for claims systems and cloud storage

Ensure the platform you use supports encryption in transit and at rest, access controls, and an immutable audit trail for legal defensibility.

Security and compliance details to record

Encryption: TLS 1.2/1.3 in transit
At rest: AES-256 storage
Audit trail: Timestamped signer IP and actions
Access control: Role-based permissions
HIPAA readiness: BAA required for PHI
Retention: Policy-based retention and legal holds

Consequences of incomplete or false submissions

Civil exposure: Denial of claims or recovery actions
Regulatory fines: State insurance sanctions possible
Criminal liability: Perjury or fraud charges if false
Data breach risk: Inadequate protection can trigger penalties
Delay costs: Longer investigations increase expense
Reputational harm: Consumer trust and regulator scrutiny

Common mistakes to avoid

  • Missing policy numbers or inconsistent insured names that block record matching.
  • Poorly labeled or low-quality evidence that cannot be used in prosecution.
  • Failure to record chain of custody for physical evidence or statements.
  • Skipping required declarations or signer authentication steps that reduce admissibility.

eSignature vendor comparison for form collection and signing

Compare common vendor capabilities and pricing models for electronic form intake and signature; signNow is listed first per comparison guidelines.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies Varies Varies Varies
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Electronic signature types: key distinctions

Understand the technical and legal differences to choose the appropriate signature method for evidentiary needs.

Criteria Electronic Signature Digital Signature
Definition broad category under esign pki-based cryptographic method
Non-repudiation audit trail-based certificate-backed
Use cases general contracts, intake forms high-assurance, regulated records
Legal basis 15 u.s.c. §7001 (esign) often used to meet 21 cfr part 11

Real-world examples of how organizations use the form

Two anonymized examples illustrate common workflows and outcomes when the form is used correctly.

Case Study 1

An SIU adjusted a high-loss property claim and found inconsistent vendor invoices

  • Investigator corroborated vendor identity discrepancy
  • The insurer recovered policy overpayments, documented the chain-of-custody, and closed the file with referral to the fraud bureau for further action.

Case Study 2

A health plan flagged repeated durable medical equipment claims from a single provider

  • Claims team attached medical records and supplier invoices
  • After review and audit, the plan suspended payments, sought restitution, and updated provider enrollment controls to reduce recurrence.

Typical signers and approvers

Claims Adjuster

A claims adjuster or handler completes factual sections, compiles attachments, and certifies the reporter's identity. They ensure policy linkage and submit the file to SIU or legal for escalation.

SIU Manager

The SIU manager reviews submitted allegations, assigns investigators, determines whether to refer externally, and signs off on investigative findings before closure or escalation.

Practical tips for accurate and defensible submissions

Implement these practices to improve investigation outcomes and reduce downstream costs.

Standardize intake
Use a single, validated form template with required fields to minimize missing data and speed automated routing.
Preserve evidence
Record chain-of-custody for physical items and time-stamp electronic evidence to maintain admissibility.
Authenticate signers
Use multi-factor authentication for internal reports that may lead to prosecution or civil action.
Train staff
Provide periodic SIU and claims training on what evidence to collect and how to document suspicious activity.

Frequently asked questions

Answers to common questions about completing, submitting, and processing the Insurance Crime Application Form.


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