test - The American Policyholder Association

Date of Birth*

Address*

Street Address Address Line 2 City State ZIP Code

Mailing Address (if different)

Street Address Address Line 2 City State ZIP Code

Business Name*

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Business Address*

Street Address Address Line 2 City State ZIP Code

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Business Phone

Your Occupation*

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Contact's Name (other than yourself)*

First Last

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Contact's Address*

Street Address Address Line 2 City State ZIP Code

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Contact's Phone*

Contact's Email

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Engineer's License Number*

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Engineer's Profession*

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Engineer's Address*

Street Address Address Line 2 City State ZIP Code

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Engineer's County*

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Date Event Occurred*

Choose closest date if exact date unknown

Witness 1's Name*

First Middle Last Suffix

Witness 1's Title*

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Witness 1's Address*

Street Address Address Line 2 City State ZIP Code

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Witness 1's Phone*

Witness 1's Email*

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Witness 1's Business Name*

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Witness 1's Business Address*

Street Address City State / Province / Region ZIP / Postal Code Country

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Witness 1's Business Phone

Witness 1's Business Email

Witness 2's Name*

First Middle Last Suffix

Witness 2's Title*

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Witness 2's Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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Witness 2's Phone*

Witness 2's Email*

Witness 2's Business Name*

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Witness 2's Business Address*

Street Address City State / Province / Region ZIP / Postal Code

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Witness 2's Business Phone

Witness 2's Business Email

Witness 3's Name*

First Middle Last Suffix

Witness 3's Title*

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Witness 3's Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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Witness 3's Phone*

Witness 3's Email*

Witness 3's Business Name*

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Witness 3's Business Address*

Street Address City State / Province / Region ZIP / Postal Code

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Witness 3's Business Phone

Witness 3's Business Email

SUBJECT PROPERTY ADDRESS (if different from address listed for Complainant above) and/or description of property location, including city and/or county.*

Put "N/A" if not applicable

Nature of Complaint*

* Fee disputes do not fall within the jurisdiction of the Division of Professions and Occupations. Please seek legal counsel and or/civil actions to remedy these types of situations

Describe Nature of Complaint*

Describe Your Complaint*

Relationship to Subject of Complaint*

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Your Insurance Company Name*

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Policy No.*

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Briefly Describe Loss*

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Briefly Describe Engineering Company's Response*

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Briefly Describe why you Think Fraud Occurred*

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What would resolve your complaint?*

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Elements of Fraud Present in This Case*

Check all that apply

Forged Signature
False Expert Testimony
Changed Engineering Report
Fraudulent Report

Will my insurance company or engineer get mad and treat me unfairly for reporting them?

This is a question that we hear all the time. It is natural human instinct to think that if we treat others nicely, they will return the courtesy. Unfortunately, that is not always the case with insurance companies or the professionals they hire. The very fact that you are reading this reveals that you most likely have not been treated fairly. Our experience has shown the opposite: It’s easier to take advantage of a ‘quiet’ victim who keeps things to themselves. Insurance companies & the experts they hire are less likely to misbehave when they know the regulators are watching. As with all business, being an educated consumer who stands up for his or her rights is the best defense against misconduct. The American Policyholder Association strongly encourages all policyholders who feel they have been cheated by their insurance company or anyone else to pursue their rights to the fullest extent of the law. It is only by fighting back that we ensure that our friends, family, and neighbors will be treated with fairness and integrity.

Please select a reporting option*

Yes I want to report this fraud to the appropriate enforcement or regulatory agency
Use my information for statistics only, I will report the Fraud myself

Date

Click here for State Fraud Reporting Info

Terms of Use Agreement*

By submitting this form I accept the terms of use of the APA and I certify that the information contained herein is accurate and truthful.

Engineering Fraud Report Form - AploRex

Will my insurance company or engineer get mad and treat me unfairly for reporting them?