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Insurance Fraud Questionnaire

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INSURANCE FRAUD QUESTIONNAIRE

Insurer Name:    Policy Number:    Claim Number:

Applicant / Insured Information

Date of Birth:    Phone:    Email:

Policy Details

Policy Type:

Annual Premium:    Policy Period From:    To:

Claim / Incident Details

Was a police report filed?    If yes, Agency:    Report No.:

Fraud Indicators Checklist

Please check any items below that apply or that you wish to disclose. Checking an item does not by itself establish fraud; it documents facts and observations relevant to the investigation.








Prior Claims / Other Insurance

Have you or any insured under this policy filed prior claims related to this type of loss within the last ten years?

Supporting Documentation Checklist

Please indicate which documents are being provided or are available for inspection:








Beneficiary Information (if applicable)

Relationship to Insured:    Allocation Percentage:

Certification, Authorization and Notice

I hereby declare, under penalty of civil and criminal penalties under applicable law, that the information provided in this questionnaire is true, complete and correct to the best of my knowledge. I understand that knowingly providing false, incomplete or misleading information in connection with a claim may constitute insurance fraud and may result in denial of coverage, cancellation of policy, restitution, fines, and/or criminal prosecution.

I authorize the insurer, its agents and representatives to investigate all statements contained herein, to obtain and review any records or documents relevant to this claim, and to disclose information to law enforcement or other insurers where required or permitted by law. I understand that this form and any attachments become part of the claim file.

I agree to cooperate with the insurer's investigation, including providing additional documentation, attending examinations under oath, and permitting inspection of damaged property if requested.

Applicant / Insured (Print Name):

Signature:

Date:

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Purpose and scope of the Insurance Fraud Questionnaire

An Insurance Fraud Questionnaire is a standardized form used by insurers and investigators to collect detailed facts when a loss or claim suggests possible fraud. It records claimant statements, policy details, incident chronology, witness information, and supporting documentation to establish or refute fraudulent activity. The questionnaire guides consistent evidence capture for internal review, subrogation, and referral to law enforcement or state fraud bureaus. Proper completion reduces investigation time, preserves chain-of-custody for documents, and creates an audit trail suitable for regulatory review and potential legal proceedings.

Why a consistent questionnaire matters for fraud investigations

Using a formal Insurance Fraud Questionnaire standardizes data capture, reduces re-contact with claimants, and creates a defensible record for denials, recoveries, or prosecution. It supports timely decisions and consistent handling across adjusters and SIU teams.

Why a consistent questionnaire matters for fraud investigations

Who typically completes or receives this questionnaire

Typical users include insurance claims adjusters, special investigations units (SIU), compliance officers, and external forensic examiners.

  • Claims adjusters: gather incident details, verify policy coverage, and note discrepancies for referral.
  • Special Investigations Units (SIU): conduct targeted interviews, perform record checks, and recommend escalation.
  • External investigators and counsel: collect forensic evidence, prepare reports for subrogation or prosecution.

The completed questionnaire becomes part of the claim file and may be shared with legal, subrogation, and regulators as appropriate.

Primary roles that interact with the form

Claims Manager

Oversees claim intake and triage, uses questionnaire responses to decide whether to open an SIU investigation, allocate investigative resources, or adjust reserves. Documents rationale for denials or recoveries and maintains records for internal audit or state insurance examiners.

Legal Counsel

Reviews completed questionnaires when litigation, regulatory reporting, or law enforcement referral is likely. Advises on evidence preservation, disclosure obligations, and coordinates subpoenas, civil recovery, or coordination with prosecutors.

Core data elements to collect on the questionnaire

Claimant Identity: Full legal name; date of birth.
Policy Details: Policy number, coverage type, effective dates.
Incident Description: Date, time, location, and narrative.
Witness Information: Names, contact, relationship to claimant.
Supporting Documents: Photos, receipts, police reports, medical records.
Signatures and Declarations: Signed statement, date, and acknowledgments.

Consequences of false statements or incomplete responses

Criminal Penalties: Misdemeanor or felony charges possible.
Civil Fines: Monetary penalties and restitution exposure.
Claim Denial: Policy benefits may be denied or rescinded.
Policy Cancellation: Insurer may cancel or non-renew coverage.
Subrogation / Recovery: Insurer may pursue repayment or liens.
Regulatory Reporting: Report to state fraud bureau or DOI.

Common mistakes when preparing or using the questionnaire

  • Incomplete claimant identifiers (e.g., missing DOB or mismatched name) that delay verification and trigger additional requests.
  • Vague incident narratives that lack chronology or supporting documents, increasing rework and investigator time.
  • Attaching unsigned or undated statements that undermine evidentiary weight or admissibility.
  • Failing to secure or log chain-of-custody for physical evidence and digital files, which weakens legal and regulatory positions.

Step-by-step: how to complete an Insurance Fraud Questionnaire

Follow a consistent sequence to collect verifiable facts, attach evidence, and document signer identity before escalating to SIU or legal.

  • 01
    1. Verify Identity: Confirm full legal name and government ID details.
  • 02
    2. Record Incident: Capture date, time, location, and a clear chronology.
  • 03
    3. Attach Evidence: Include photos, receipts, police reports, and medical records.
  • 04
    4. Sign and Date: Obtain claimant signature and signing date; log method.

Where completed questionnaires are routed

After completion the form should follow an internal workflow that ensures review by the appropriate investigative and legal teams.

  • Claims File: Primary storage for the claim record and immediate adjuster review.
  • Special Investigations Unit: SIU receives questionnaires flagged for potential fraud.
  • Legal / Subrogation: Legal team reviews for recovery or litigation potential.
  • Regulatory Report: Send to state fraud bureau when required by statute or policy.

Configuring an online questionnaire workflow

Set up form logic, signer authentication, and evidence attachments to reduce manual steps and preserve the audit trail.

Field Configuration
Authentication method Email link, SMS code, or KBA where needed.
Conditional fields Show follow-up questions when red flags appear.
Auto-attach evidence Allow upload of photos and PDFs from claimant.
Audit trail retention Record IP, timestamp, and signer actions.

Technical considerations for eSubmission and storage

Choose a platform that preserves an audit trail, supports the required file formats, and meets industry compliance needs.

  • File formats: PDF, DOCX, and image files supported.
  • Integrations: Connect to claim systems, CRM, and cloud storage.
  • Authentication options: Email, SMS, KBA, or multi-factor available.

Typical timelines and processing expectations

Although statutory deadlines vary, common operational SLAs help ensure timely investigation and regulatory compliance.

Initial questionnaire issuance:

Issue within 7–30 days of claim intake, depending on risk factors.

Claimant response expected:

Request reply within 14 calendar days to avoid delays.

SIU review window:

Complete initial SIU triage within 7 business days.

Regulatory reporting:

Report suspected fraud per state DOI deadlines.

Evidence preservation:

Preserve originals until investigation and legal review complete.

How the Insurance Fraud Questionnaire differs from related documents

Compare this questionnaire with commonly used documents to avoid duplicative collection and to choose the correct form for each purpose.

Criteria Insurance Fraud Questionnaire Proof of Loss
Primary purpose fact collection for fraud screening claim valuation and payment
Signature requirement yes, declaration & signature yes, sworn signature
Typical use investigation and siu triage settlement and claims payment
Legal weight investigative record for referral contractual claim document

Pricing: eSignature providers commonly used for questionnaires

Platform pricing and feature availability affect per-document cost and compliance capabilities for electronic questionnaire workflows.

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 Yes
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Practical examples of questionnaire use

Two concise scenarios show how the questionnaire supports both auto and medical claim investigations.

Auto Claim SIU

An adjuster notices inconsistent accident times and requests the questionnaire to document chronology and witnesses

  • SIU flags the claim for further forensic inspection of photos and repair invoices
  • The completed questionnaire and attachments provided basis for a subrogation demand and supported coordination with local law enforcement.

Healthcare Loss Review

A large medical billing claim triggers a questionnaire to capture treatment dates and provider invoices

  • Discrepancies in provider addresses prompt verification requests
  • The form and supporting records enabled the insurer to recover overpaid amounts and update provider watchlists.

Authentication, notarization, and witness steps

When signatures, notarization, or witnesses are required, follow a clear sequence to authenticate and preserve evidence for legal use.

01

Step 1: Identity Verification

Confirm government-issued ID and record verification method.

02

Step 2: Signer Consent

Obtain and record consent to transact electronically when required.

03

Step 3: Signature Capture

Collect signature and date; note electronic method used.

04

Step 4: Notary Execution

If needed, perform in-person or RON notarization per state rules.

05

Step 5: Witness Attestation

Obtain witness signatures if state or form requires them.

06

Step 6: Audio/Video Recording

For RON, retain audio-video session per state retention rules.

07

Step 7: Audit Trail Storage

Store IP, timestamps, and signer metadata with document.

08

Step 8: Evidence Preservation

Secure originals and digital files pending legal review.

FAQs: common questions about the Insurance Fraud Questionnaire

Answers to frequent questions about signing, legal validity, evidence, and what to do when responses are incomplete or suspicious.


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