Insurance Fraud:

Use this form to report suspected fraud. You don't need to complete all the boxes to submit this report. To assist us in reviewing this report, please be sure to include complete information about the person or organization you suspect of committing fraud.

Your Information (Optional)

Your name Address City State Zip Home phone Work phone E-mail address

Person or Company You Suspect of Fraud

Name Address City State Zip Home phone Work phone Dates of service(s)

Person This Affected

Name Plan I.D.# Address City State Zip Home phone Work phone Report

If you don't want to submit this form online, you can also contact us by: Fax (916) 350-6930 Mail CareAmerica Life Insurance Company Special Investigations 4203 Town Center Blvd El Dorado Hills, CA 95762 E-mail