Can the report be signed electronically?

Yes. Electronic signatures are valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and reliable record retention are present.

When is a notarization required?

Notarization is generally not required for insurer internal reports but may be necessary for attachments or affidavits used in court; verify state notary rules before notarizing.

How should PHI be handled?

Limit PHI to the minimum necessary, obtain required authorizations, and ensure secure transmission to comply with HIPAA and state privacy laws.

What if the claimant disputes the findings?

Document your basis, preserve evidence, and follow insurer appeal procedures; maintain investigator notes and chain-of-custody to support the report.

How long must we retain the report?

Retain investigative records per insurer policy and applicable laws — HIPAA 6 years, IRS minimums, and additional state-specific requirements where applicable.

Who can access investigative files?

Limit access to authorized personnel on a need-to-know basis; maintain role-based permissions and record all access events for audit purposes.

Electronic Signature
Templates
Insurance
Insurance Crime Report

Insurance Crime Report

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

INSURANCE CRIME REPORT

Use this form to report an incident involving suspected criminal activity that may give rise to a claim under an insurance policy. Complete all applicable sections. The information you provide will be used for investigation, claim evaluation, and potential recovery/subrogation. Deliberate misrepresentation of facts may result in denial of coverage and civil or criminal penalties.

1. Insured / Applicant Information

Insured Name Mailing Address

Date of Birth:

Phone:

Email

2. Policy Information

Insurer / Company

Policy Number:

Agent / Broker:

Policy Type:

Coverage Limit:

Deductible:

Premium:

Policy Period From:

To:

3. Incident Details

Date of Incident: Time (approx.):

Location of Incident Type of Crime (check all that apply)

Theft Burglary Robbery Vandalism

Arson Fraud / Forgery Identity Theft Embezzlement

Other (specify):

Description of Incident

4. Property / Loss Detail

Provide a full description of items lost or damaged. If additional space is required, attach a separate inventory and indicate total below.

Item 1 — Description

Serial/ID:

Approx. Value:

Where Located:

Item 2 — Description

Serial/ID:

Approx. Value:

Where Located:

Total Estimated Loss / Damage

5. Police Report & Witnesses

Was the incident reported to law enforcement? Yes No

Police Department Report Number Date Reported Investigating Officer

Witnesses (names and contact information)

6. Documentation Checklist

Please indicate which documents are attached or will be provided upon request.

Photographs of scene/items
Original receipts / proof of purchase
Surveillance footage
Bank / credit card statements
Witness statements
Copy of police report
Other documents (specify):

7. Coverage Affected / Immediate Action

Is emergency mitigation required (temporary repairs, boarding, secure storage)? Yes No

Describe any immediate actions taken to protect property or prevent further loss

8. Beneficiary / Payee for Settlement

If settlement funds are to be paid to a payee other than the insured, provide payee details below.

Payee / Beneficiary Name

Relationship to Insured:

Percentage of Proceeds:

9. Exclusions, Authorization and Certification

I certify that the information provided in this report is true and complete to the best of my knowledge. I understand that false statements or material omissions in support of a claim may constitute insurance fraud, subject to policy denial and civil or criminal penalties. I authorize the insurer, its representatives and law enforcement to investigate the facts, obtain records, and exchange information necessary to evaluate this report and any subsequent claim. The insurer retains all rights of subrogation and recovery against responsible third parties for any payments made.

I agree to cooperate fully with the insurer's investigation, including providing access to damaged property, records, and witnesses, and to execute documents necessary to effect recovery. I understand that coverage is determined in accordance with the terms, conditions and exclusions of the policy and that this report is not acceptance of coverage or an admission of liability by the insurer.

By signing below I affirm that I understand and accept the statements above and that I will promptly provide any additional documentation requested by the insurer.

Printed Name:

Signature:

Date:

What the Insurance Crime Report Is and when it’s used

An Insurance Crime Report documents suspected fraud, material misrepresentation, or deliberate loss staging associated with an insurance claim. It collects claimant and policy identifiers, incident facts, investigative findings, supporting evidence, and the investigator's conclusions. Insurers use the report to support internal claim decisions, to refer matters to special investigations units or law enforcement, and to create an auditable record for regulators. The report can be prepared as a paper form or an electronic record that meets ESIGN (15 U.S.C. ch. 96) and state UETA requirements for legal enforceability.

Why a clear Insurance Crime Report matters

A complete, accurate report preserves evidence, supports defensible claim decisions, enables timely referral to fraud units or prosecutors, and reduces the risk of improper payments. It creates a consistent audit trail for internal review and regulatory examination.

Who typically prepares and reviews these reports

Maintain role-based distribution: investigators keep originals, claims teams retain case summaries, and legal units receive complete investigative files when escalation is necessary.

Insurance adjusters: Conduct on-scene fact gathering, document policy and loss details, and submit findings to the special investigations unit.
Fraud investigators: Compile evidence, perform interviews and background checks, and prepare a case narrative suitable for referral to prosecutors.
Law enforcement and prosecutors: Receive reports when criminal conduct is suspected and evaluate whether to open a formal investigation.

Core sections to include in a professional report

A structured report improves clarity and defensibility. Include standardized sections so reviewers can quickly assess authenticity, evidence, and next steps.

Case Header

Claim number, policy number, insurer contact, investigator name, and report date for unique identification.

Claimant Details

Full legal name, DOB, contact, policyholder relationship, and government ID references where applicable.

Incident Summary

Concise chronology of events, location, time, reported loss type, and immediate observations at the scene.

Evidence Inventory

List of photos, videos, receipts, repair estimates, and chain-of-custody notes for each item collected.

Investigative Findings

Facts gathered, witness statements, discrepancies noted, and analysis linking evidence to suspicious indicators.

Conclusion & Disposition

Investigator opinion, recommended referral or denial, required follow-up actions, and signature with date.

Step-by-step: completing an Insurance Crime Report

Follow these steps in order to create a clear, auditable report.

01

1. Gather ID and Policy: Verify claimant identity and policy details before documenting facts.
02

2. Document Scene: Photograph damage, record measurements, and note environmental conditions.
03

3. Collect Evidence: Secure receipts, repair estimates, and witness contact information with timestamps.
04

4. Finalize Narrative: Write a chronological account, note inconsistencies, and sign the completed report.

Where the completed report should go next

Routing ensures the right stakeholders get the report for review, action, or escalation.

Claims File: Attach the report to the insured's claim record for adjudication and payment analysis.
Special Investigations Unit: Forward reports with suspected fraud for deeper investigative work and evidence collection.
Legal / Compliance: Provide copies when regulatory reporting or litigation support is required.
Law Enforcement Referral: Submit when criminal conduct is evident and include chain-of-custody documentation.

Digital signing and secure eSubmission considerations

Ensure the chosen eSubmission method complies with ESIGN (15 U.S.C. ch. 96) and state UETA rules and that privacy safeguards are in place for PHI.

Authentication: Email, SMS, or stronger multi-factor verification
Audit Trail: Timestamped event log with IP and action history
Integrations: CRM, claims systems, and cloud storage connectors

Configuring an online report workflow

Standardize fields, signer authentication, and storage so each report is consistent and auditable.

Field	Configuration
Signature Authentication	Email + SMS code or corporate SSO for staff signers
Conditional Fields	Show additional evidence fields when 'suspicious' is selected
Bulk Submission	Enable bulk send for multi-claim investigations
Record Storage	Encrypt at rest and retain per retention policy

Typical eSignature vendor comparison for report signing

Comparison of common vendor attributes and entry pricing models. signNow appears first per vendor conventions; verify final plan terms with each provider before purchase.

	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 by plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes (Premium tier)	Yes	Yes	Yes	Varies
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes (BAA available)	Yes	Yes	No	No

Timing expectations and internal deadlines

Prompt reporting preserves evidence and enables timely investigation; internal SLAs depend on insurer policies and regulatory obligations.

Initial Report Timing:

Prepare and file the report as soon as possible after discovery, ideally within 24–72 hours

Internal Investigation SLA:

Common insurer SLAs: 7–30 days for initial investigative findings

Law Enforcement Referral:

Refer promptly when criminal indicators exist; state rules may require specific timelines

Evidence Preservation:

Preserve physical and digital evidence immediately to avoid spoliation

Regulatory Reporting:

Comply with state insurance department requirements for suspected fraud reporting

Consequences of incorrect or incomplete reporting

False Reporting: Civil liability or criminal charges in some jurisdictions

Privacy Violations: HIPAA or state privacy breaches for mishandled PHI

Regulatory Fines: Penalties from state insurance regulators

Evidence Loss: Spoliation undermines prosecutions and recoveries

Claim Appeals: Incomplete reports increase reversal risk on appeal

Reputational Harm: Public exposure following regulatory action or litigation

Common mistakes to avoid when preparing the report

Incomplete timelines or missing timestamps that prevent cross-referencing with phone records or surveillance footage.
Failing to record chain-of-custody for physical evidence, which can render items inadmissible in court.
Overbroad inclusion of third-party medical or financial records without redaction or patient authorization.
Using ambiguous language or conclusory statements rather than documenting observable facts and verifiable sources.

Practical examples of how reports support investigations

The following vignettes show how a structured report clarifies findings and enables next steps.

Insurance Investigation Example

An adjuster documents inconsistent repair receipts and photos

Investigator corroborates with vendor logs
The report’s evidence package supported a referral to the special investigations unit and prevented a wrongful payout by clearly showing fabrication.

Law Enforcement Referral

A suspicious arson claim includes time-stamped video and witness statements

Chain-of-custody was recorded for recovered accelerant samples
The complete report enabled a successful criminal investigation by providing admissible documentation and investigator testimony contacts.

Security controls to protect investigative records

Encryption in Transit: TLS 1.2/1.3

Encryption at Rest: AES-256 encryption

Audit Trail: Timestamped logs and activity history

Compliance Certifications: SOC 2 Type II, ISO 27001

HIPAA Support: BAA available for PHI handling

Access Controls: Role-based permissions and SSO options

Frequently asked questions about the Insurance Crime Report

Answers to common operational and legal questions to help avoid delays and protect sensitive information.

Need help? Contact support

Can the report be signed electronically?
Yes. Electronic signatures are valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and reliable record retention are present.
When is a notarization required?
Notarization is generally not required for insurer internal reports but may be necessary for attachments or affidavits used in court; verify state notary rules before notarizing.
How should PHI be handled?
Limit PHI to the minimum necessary, obtain required authorizations, and ensure secure transmission to comply with HIPAA and state privacy laws.
What if the claimant disputes the findings?
Document your basis, preserve evidence, and follow insurer appeal procedures; maintain investigator notes and chain-of-custody to support the report.
How long must we retain the report?
Retain investigative records per insurer policy and applicable laws — HIPAA 6 years, IRS minimums, and additional state-specific requirements where applicable.
Who can access investigative files?
Limit access to authorized personnel on a need-to-know basis; maintain role-based permissions and record all access events for audit purposes.

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