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Get Uniform Suspected Insurance Fraud Form Fillable

Etailed synopsis. Attach additional pages, if necessary. Date of Loss / Injury: Address of Loss / Injury: (City) (State) Claim #: Reserve Amount: Amount Paid: $ $ Loss Amount: Settlement Amount: $ $ Dates of Services: Description of Service: to: (Zip) Policy #: Procedure Code # s: CPT CDT Civil Litigation Pending: Yes No Date Paid: Date Paid: Insurance Type: PC WC HC Auto Life Disability Subject Information Type: Name (Last / Business): (First): (Middle): Date of Birth: Age: SSN:.

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