N.Y. Comp. Codes R. & Regs. tit. 11 § 86.5

Current through Register Vol. 46, No. 45, November 2, 2024

Section 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 Insurance Frauds Bureau. Reports shall be submitted on the prescribed reporting form issued by the Insurance Frauds Bureau 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

INSURANCE DEPARTMENT

INSURANCE FRAUDS BUREAU REPORTING FORM

DATE ____________

To:

State of New York

(1) Information furnished by:

Insurance Department Company

Frauds Bureau Name:

60 West Broadway ________

New York, NY 10013 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.[FN*] 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. Is this matter the subject of any civil law suit or regulatory action including liquidation or insolvency proceedings? If so, please describe.

____________

10. 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.

____________

11. 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 ________

12. 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.

[FN*] Major insurance fraud or corruption is defined as:

(1) a scheme which 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 which involves less than $100,000, this form may still be submitted or a referral may be made by letter.

N.Y. Comp. Codes R. & Regs. Tit. 11 § 86.5