Establishing secure connection…Loading editor…Preparing document…

Insurance Fraud Statement

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

INSURANCE FRAUD STATEMENT

Insured / Applicant Information

Policy Details

Coverage (select all that apply)






Exclusions

List any policy exclusions, endorsements, or limitations known to you as they pertain to the matters covered by this statement. Provide specific article or endorsement references where available.

Beneficiary Designation (if applicable)

Insurance Fraud Acknowledgment and Reporting

The undersigned declares and acknowledges that all statements and information provided in connection with the policy identified above, and any related claim or application, are true and correct to the best of the undersigned's knowledge and belief. The undersigned understands and agrees that:

  1. Any person who knowingly presents false information or omits material information in connection with an insurance application or claim may be subject to civil or criminal penalties, including fines, restitution, policy rescission, denial of benefits, and imprisonment.
  2. The insurer reserves the right to investigate, verify, and refer any suspected fraudulent activity to appropriate authorities and to pursue civil remedies, including recovery of damages and costs of investigation.
  3. The undersigned authorizes the release of relevant records and information to the insurer and its representatives for the purpose of investigation, verification, and adjudication of any claim or application.
  4. This statement is given for the purpose of documenting the undersigned's awareness of the legal consequences of insurance fraud and of confirming the accuracy of the information provided.

Have you ever been charged with or convicted of insurance fraud or any crime involving dishonesty or false statements?      

Has a claim related to the matters described in this statement been filed previously?         If yes, Date of Loss:

Certification

I certify under penalty of perjury and pursuant to applicable law that the foregoing statements are true and complete. I understand that this Insurance Fraud Statement will be relied upon by the insurer in determining rights and obligations under the policy and with regard to any claim. I further acknowledge that I have read and understand the potential civil and criminal consequences of making false statements or submitting fraudulent documentation.

Printed Name:

Signature:

Date:

Enter text✕
Prepare your document for signing right on this page
  • 01 Edit the text and complete the fields
  • 02 Click Sign Now and on the next screen add recipients and signature fields in SignNow
  • 03 Start your free trial to sign and send your doc
Sign Now

What an Insurance Fraud Statement Is and when it's used

An Insurance Fraud Statement is a signed declaration provided to an insurer or investigator that describes facts about a claimed loss and affirms the signer's knowledge and truthfulness. It documents the circumstances of an incident, summarizes supporting evidence, and records the claimant's and witnesses' statements to assist claim assessment, investigation, or subrogation. Insurers rely on these statements to determine benefits, detect misrepresentation, and initiate investigations; false statements can lead to claim denial, civil recovery, or criminal prosecution under applicable state law.

Why this statement matters for claims and investigations

An accurate Insurance Fraud Statement creates a documented record that supports claim decisions, protects parties from later disputes, and helps insurers detect abuse. Under U.S. law, electronic versions can be enforceable when they meet ESIGN and UETA criteria, though some exceptions apply for certain court filings and testamentary documents.

Why this statement matters for claims and investigations

Who typically completes or receives an Insurance Fraud Statement

Multiple parties interact with this statement to document claims and investigations and to certify factual accounts.

  • Claims adjusters and special investigation units gather signed statements from claimants and witnesses during routine investigations.
  • Policyholders and claimants provide sworn or unsigned statements describing the event, damages, and witness information.
  • Attorneys, public adjusters, and brokers may prepare or review statements before submission to insurers or law enforcement.

Clear role assignment speeds processing and reduces downstream disputes; ensure the correct party completes the appropriate sections.

Representative signer profiles

Claims Adjuster

Claims adjusters collect and record statements to evaluate coverage, liability, and fraud indicators. They use standardized forms to capture chronology, witness contact details, and evidence references for internal files and potential legal follow-up.

Policyholder

The policyholder provides the primary factual account and signs to attest to accuracy. Their statement should match supporting evidence (photos, receipts, police reports) to avoid inconsistencies that could trigger denial or investigation.

Stepwise process to complete the statement

Follow these steps to prepare, verify, and submit a complete Insurance Fraud Statement to the insurer or investigator.

  • 01
    Gather details: Collect dates, times, witness names, and supporting documents.
  • 02
    Draft the account: Write a factual, chronological description without conjecture.
  • 03
    Attach evidence: Include photos, receipts, police reports, and estimates.
  • 04
    Sign and submit: Sign (wet or e-sign) and send via insurer's accepted channel.

How an Insurance Fraud Statement moves through review

A completed statement follows a short review workflow before final claim determination or investigative escalation.

  • Prepare: Complete form and gather evidence for submission.
  • Authenticate: Confirm signer identity via ID, SMS code, or insurer authentication.
  • Review: Adjuster or investigator reviews content and corroborating evidence.
  • Resolve: Claim is approved, denied, or referred for further investigation.

Configuring an electronic statement workflow

Common digital workflow settings ensure secure collection, routing, and retention of signed Insurance Fraud Statements.

Field Configuration
Authentication Email link, SMS code, or knowledge-based verification
Signature Type Click-to-sign, typed name, or drawn signature image
Routing Sequential to adjuster then supervisor
Retention Encrypted storage, audit trail, and export on request

Platform capabilities to capture and preserve statements

Ensure the platform you use supports strong authentication, secure storage, and exportable audit trails for compliance and evidentiary use.

  • Authentication: Email, SMS, KBA, or SSO
  • Integrations: Salesforce, NetSuite, Google Workspace
  • File formats: PDF, DOCX, PDF/A

Common preparation mistakes to avoid

  • Omitting precise dates or times: vague timelines create opportunities for inconsistency and investigator follow-up, delaying resolution.
  • Failing to attach evidence: referencing photos or reports without attachments weakens the statement's credibility and may prompt denial.
  • Using speculative language: opinions or guesses can undermine factual statements and expose the signer to perjury or fraud allegations.
  • Entering inconsistent names: mismatched names between ID, policy, and statement trigger identity verification delays and potential claim holds.

Potential consequences for inaccurate or fraudulent statements

Criminal Liability: Felony or misdemeanor prosecution under state insurance fraud statutes
Civil Recovery: Repayment of claim proceeds plus interest and insurer damages
Claim Denial: Immediate denial of benefits for misrepresentation
Fines: Administrative fines or penalties imposed by regulators
Perjury Exposure: Potential charges if signed under oath and knowingly false
Record of Fraud: Damage to insurability and higher premiums later

Typical timelines and expectations for submission and review

Timelines vary by insurer and state statute; submit promptly and check policy language for reporting deadlines to avoid coverage issues.

Immediate Reporting:

Submit as soon as reasonably possible after the incident to preserve rights

Insurer Acknowledgment:

Insurers often acknowledge receipt within 5–10 business days

Investigation Window:

Initial investigation and evidence request commonly occur within 30–90 days

Statutory Deadlines:

Some states limit claims or fraud reporting windows; check state law and policy

Appeal Periods:

Policy appeal windows vary; follow insurer instructions exactly

Key milestones in the statement lifecycle

Track these milestones from preparation through final resolution to monitor progress and preserve rights.

01

Preparation

Gather evidence and complete the statement with factual detail.

02

Submission

Send via insurer portal, secure email, or recorded mail.

03

Investigator Review

Adjuster or SIU examines statement and corroborating materials.

04

Resolution

Claim is adjudicated, paid, denied, or referred for legal action.

How the Insurance Fraud Statement compares with related documents

Compare common document types used in claims handling to understand legal weight, notarization needs, and e-sign acceptance.

Document Type Insurance Fraud Statement Affidavit Proof of Loss
When used claim intake court or sworn evidence claims payment
Legal weight investigative record sworn under oath contractual claim detail
Notarization usually not required often required varies by insurer
E-sign acceptable yes if esign/ueta met depends on jurisdiction often accepted

Digital signing platforms and pricing for statement workflows

Selected eSignature vendors and core plan characteristics for collecting and retaining Insurance Fraud Statements; signNow appears first per vendor 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 No No Yes, limited Yes, limited
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Frequently asked questions about Insurance Fraud Statements

Answers to common procedural and legal questions about preparing, signing, and submitting Insurance Fraud Statements.


Need help? Contact support

be ready to get more
Join over 28 million airSlate SignNow users
Sign Now
Company
Forms
Pricing
Resources
Knowledge base
Other Products
© 2026 airSlate Inc. All rights reserved.