We proactively prosecute insurance fraud and appreciate your assistance.

The information can be sent anonymously, although we encourage the completion of the personal information section.

Remember the more information that is provided the more effective we can be in investigating and resolving the matter.

Republic Western Fraud Report Form

Claimant Information
Claim Number:
Date of Loss:
City of Loss:
State of Loss:
Equipment Number: (if applicable)

Primary Involved Party
First Name:
Last Name:

Additional Involved Parties
First Name:
Last Name:
First Name:
Last Name:

Reason for Suspected Fraud

Personal Information
First Name:
Last Name:
Phone Number:
Fax Number:
Email Address:



Copyright 2001 Republic Western Insurance Company. All rights reserved. Call us at 1-800-858-0317