11 CRR-NY 86.5NY-CRR
STATE COMPILATION OF CODES, RULES AND REGULATIONS OF THE STATE OF NEW YORK
TITLE 11. INSURANCE
CHAPTER IV. FINANCIAL CONDITION OF INSURER AND REPORTS TO SUPERINTENDENT
SUBCHAPTER A. RULES OF GENERAL APPLICATION
PART 86. REPORTS OF SUSPECTED INSURANCE FRAUDS TO CRIMINAL INVESTIGATIONS UNIT; REQUIRED WARNING STATEMENTS
11 CRR-NY 86.5
11 CRR-NY 86.5
86.5 Reports of fraudulent acts.
Any person licensed pursuant to the provisions of the Insurance Law who determines that an insurance transaction or purported insurance transaction appears to be fraudulent or suspect shall submit a report thereon to the Criminal Investigations Unit. Reports shall be submitted on the prescribed reporting form issued by the Criminal Investigations Unit or upon any other form approved by order of the superintendent. Reporting may also be done by means of any electronic medium or system approved by order of the superintendent.
STATE OF NEW YORK
DEPARTMENT OF FINANCIAL SERVICES
CRIMINAL INVESTIGATIONS UNIT REPORTING FORM
DATE
To:
State of New York
(1) Information furnished by:
Department of Financial Services
Company
Criminal Investigations Unit
Name:
One State Street
____________
New York, NY 10004
Address:
____________
____________
NAIC #
____________
PLEASE PRINT/TYPE INFORMATION
(2) Brief statement of suspect transaction and dollar amount of claim:
(3) Identify parties to suspect transaction (name, address and relation to transaction):
(4) Identify your policy, claim or reference number under which the above transaction is recorded:
(5) Name, title, address and telephone number of individual in your company who can provide detailed information:
Name Title Address Tel.#
(6) Have you reported this transaction to any other law enforcement agency?
If yes, furnish name of agency, address, person contacted, date of report and telephone #.
Signed:
Title:
IFB-1
UNITED STATES DEPARTMENT OF JUSTICE
INSURANCE RELATED CRIMINAL REFERRAL FORM
To Be Used for Criminal Referrals in Suspected Cases of Major Insurance Fraud or Corruption.* Please provide as much of the requested information as possible, but if any information is unavailable leave the answer blank.
1. Name and Location of Insurance Company/Agency/Entity
Name
Location street city state zip
Location of Suspected Offense:
2. Asset Size of Insurance Company/Agency/Entity
3. Approximate date and dollar amount of loss due to suspected violation.
Date
Amount
Month Year
4. Summary characterization of the suspected violation. Check appropriate item(s).
__Defalcation/embezzlement
__ False Statement by insurance company (e.g. assets/liabilities; ownership; reserves)
__ Misuse of Position or Self Dealing; other abuses by insurance company insiders
__Check Kiting
__Bank Fraud
__ Bank Secrecy Act/Money Laundering
__Employee Benefit Plans (ERISA)
__METS & MEWAS
__Reinsurance
__Tax Violations
__Public Corruption/Bribery
__Securities Fraud
__Other (Describe)
__
__
5. Person(s) Suspected of Criminal Violation (If more than one, use Continuation Sheet.)
a. Name first middle last
b. Address street city state zip
c. Date of Birth________ Social Security No. ______
(if known)
mo/day/yr
(if known)
d. Relationship to the insurance entity. Check all applicable item(s)
__Officer
__Director
__Employee
__Accountant
__Consultant
__Third Party Administrator
__Managing General Agent
__Agent/Broker
__Appraiser
__Lawyer
__ Employee Benefit Plan Service Provider
__Stockholder
__Policyholder
__Other (Specify)
__ ________
__ ________
e. Is person still affiliated with the insurance entity?
__yes __no If no, __Terminated__Resigned
FORM OMB-1105-0054
EXP. AUG.95
f. Is person affiliated with any other insurance entities?
If yes, please identify
6. Explanation/Description of Suspect Activity (You may use a separate sheet)
Give an account of the suspected criminal activity.
7. Witnesses
If known, list any witnesses who might have information about the suspected violation and describe their position or employment. Indicate if they have been interviewed. (Use continuation sheet if necessary.)
Name
Position
Address
Tele.
Interviewed
Yes
No
(1)
______________
__ __ ______________
(2)
______________
__
__
8. Is this matter the subject of any civil law suit or regulatory action including liquidation or insolvency proceedings?
If so, please describe.
9. Has a referral or complaint been made about this or a related matter or individual to a state insurance regulatory agency, law enforcement, a U.S. Attorney's Office, State Attorney General's Office or other prosecutor's office?
If so, please describe.
10. Distribution Information
a. Send one copy to the office of the Federal Bureau of Investigation (FBI) nearest to where the suspected offense took place.
FBI office to which form was sent:
city/state
b. If the allegations are false claims or mail fraud, please send one copy to the Postal Inspection Service nearest to where the suspected offense took place. Postal Inspection Service office to which form was sent:
city/state
c. Send one copy to: U.S. Department of Justice, Criminal Division, Fraud Section, 10th & Pennsylvania NW, Washington, DC 20530, Attention: Karen Morrissette, Deputy Chief.
d. In addition, if the allegations in this referral involve any of the categories as listed below, please send a copy to the corresponding agency listed below and indicate that the referral was sent.
1. Employee Benefit Plans (ERISA); Multiple Employer Trusts or Welfare arrangements.
Send to: Office of Labor Racketeering
U.S. Department of Labor
Room S-5012
200 Constitution Avenue
Washington, DC 20210
Referral sent
Yes
__
No
__
Pension & Welfare Benefits
Administration
Enforcement Section
U.S. Department of Labor
Room N - 5702
200 Constitution Avenue
Washington, DC 20210
Referral sent
Yes __ No __
2. Tax Violations; Bank Secrecy Act/Money Laundering
Send to: Internal Revenue Service
Criminal Investigation Division
1111 Constitution Avenue
Room 2143
Washington, DC 20224
Attn: Director of Operations
Referral sent
Yes __No __
11. Person to contact for further information about referral
Name
Position
Organization
Phone No.
Date of referral
Public reporting for this collection of information is estimated to average one hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing this burden to Fraud Section, Criminal Division, U.S. Department of Justice, Washington, DC 20530; and to The Office of Management and Budget, Washington, DC 20503.
Footnotes
*
Major insurance fraud or corruption is defined as: (1) a scheme that resulted in a loss to the state, company, policyholders, a multiple employer trust (MET), a multiple employer welfare arrangement (MEWA), or participants in METS or MEWAs of more than $100,000 or a gain to the perpetrator of more than $100,000; or (2) insurance-related public corruption, such as bribery of a public official, regardless of the amount. Please exclude all arson cases or matters. In the event a fraud is uncovered that involves less than $100,000, this form may still be submitted or a referral may be made by letter.
11 CRR-NY 86.5
Current through June 30, 2021
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