Fillable New York Ifb 1 Form in PDF
The New York Ifb 1 form plays a crucial role in reporting suspected insurance fraud to the state's Department of Financial Services. This form serves as a structured way for individuals and organizations to provide essential details about potentially fraudulent transactions. Key components include information about the suspect transaction, such as the date and amount of loss, along with the type of loss—whether it involves auto, medical, or workers' compensation claims. Additionally, the form requires the identification of the parties involved, including names and addresses, which helps in the investigation process. It also prompts the reporter to include their policy or claim number, ensuring that all relevant information is linked to existing records. Furthermore, the Ifb 1 form asks if the transaction has been reported to other law enforcement agencies, fostering collaboration among various authorities. Completing this form accurately and thoroughly can aid in the effective identification and prosecution of fraudulent activities, ultimately protecting both insurers and consumers in New York.
Preview - New York Ifb 1 Form
NEW YORK STATE
DEPARTMENT OF FINANCIAL SERVICES INSURANCE FRAUDS BUREAU
25 BEAVER STREET
NEW YORK, NY 10004
DATE:
1). Information furnished by:__________________________
Address: _______________________________________
_______________________________________
NAIC # _______________________________________
Previously submitted? Yes ____ Log # ___________ No_____
PLEASE PRINT/TYPE INFORMATION
2)Brief statement of suspect transaction. Date of loss ___________ Amount of loss ____________ County_____
Type of loss: Auto___
If Auto or
STATEMENT
3)Identify parties to suspect transaction: Name(s) Address(es)
Additional information on suspect(s)
If Auto or Fraudulent cards give VIN # _________________________ Plate or License # ____________________
4) Identify your policy, claim or reference number under which the above transaction is recorded:
Claim # __________________________ Claim status_____________________________________________
Reference #_____________________________ Policy # _________________________ SIU #_______________
5)Name, title, address & telephone number of individual in your company who can provide detailed information:
NAME__________________________________________ TITLE _________________________________
ADDRESS __________________________________________________ TELEPHONE # _____________
6)Have you reported this transaction to any other law enforcement agency? Yes ____________ No____________
If yes, please furnish: Agency _________________________________________________________________
Address ___________________________________________________________________________________
Person contacted _________________________ Telephone #____________________Date of report _________
Continue on reverse or attach additional sheets as necessary.
Signed: _______________________________
Title: ________________________________
http://www.dfs.ny.gov
Form Characteristics
| Fact Name | Details |
|---|---|
| Governing Authority | The New York IFB-1 form is governed by the New York State Department of Financial Services. |
| Purpose | This form is used to report suspected insurance fraud to the Insurance Frauds Bureau. |
| Submission Requirements | Individuals must provide detailed information regarding the suspect transaction, including names and addresses of involved parties. |
| Reporting to Other Agencies | Filers must indicate if they have reported the transaction to any other law enforcement agency, providing relevant details. |
| Contact Information | Submitters must include contact details of an individual in their company who can provide further information about the report. |
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