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TIP Report
Directions: Fill out this online form in order to submit a TIP Report to the Special Investigation Unit. You may choose to remain anonymous if you would like. The only thing we require is that you supply a narrative description of the unusual activity in the textbox at the bottom of this form. Thank you for the TIP.
Confidentiality
CAUTION! THIS IS A PRIVILEGED AND CONFIDENTIAL DOCUMENT
This document is privileged and, as such, should not be discussed verbally or in writing nor released to anyone outside of the State Fund organization. Should this document be sought by subpoena or subpoena duces tecum it qualifies as privileged under insurance code section 1877.4 and should not be produced. This document is intended for internal communication only and is not intended for distribution outside of State Fund.

Reporter Information

Do you wish to remain anonymous?
First Name
Last Name
E-mail

General Information

Case Type *
Source Location
Group #
Policy #
Policy Year
Claim #
Date of Injury

Involved Parties

Party Type
First Name
Last Name
Address
County
State
City
Zip Code
E-mail
Phone
Ext
Phone
Ext
Driver's License
Business Name
MMDDYYYY
Date of Birth
/ /

Notes
Spell Check


Please click on "Add Involved Party" to save data



#TypeNamePhone NumberAddress

Allegation Information

Allegation
Allegation Narrative
Spell Check


Please click on "Add Allegation" to save data



#Allegation TypeDateRecorded ByAllegation Narrative









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