New York Form Ifb 1 – Fill Out and Use This PDF

PLEASE PRINT/TYPE INFORMATION

2)Brief statement of suspect transaction. Date of loss ___________ Amount of loss ____________ County_____

Type of loss: Auto___ No-Fault___ Medical___ Workers Comp. __ Fraudulent ID cards__ Other_____________

If Auto or No-Fault, was this policy application submitted via NYAIP? Y N

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

IFB-1 REV 8/11