Acknowledgments. In cases such as this, the following recommendations should be considered:

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1 The tips contained in the following pages are for experienced insurance investigators. They are not checklists to be completed and they are not mandatory in any way. Your investigative expertise and judgment are relied upon to determine what actions are necessary to ensure a thorough investigation is conducted. These tips apply primarily to the investigation of single claims, however understanding the elements of a single claim investigation is crucial to conducting a multi-claim, multicarrier investigation. In addition, many of these tips provide information relevant to an investigation of any type. Acknowledgments Many investigators contributed their knowledge and personal tipsheets to complete this comprehensive document. We thank those investigators who donated their time and expertise, thus allowing fraud fighting organizations to benefit from their experience. A special thanks is given to Mr. Todd Willis, an investigator for CNA Insurance, who provided a major portion of the TipSheets by permitting the use of his manuscript on combating insurance fraud. PRODUCT LIABILITY CLAIM INVESTIGATION SCENARIOS TIPS. Investigations into product claims can be time consuming and because of the various types of contamination, each will have various investigative leads, which differ from other claims. As an example, If blood is alleged to be on a product consumed by the claimant, if any blood remains, this blood may be able to be analyzed to determine if it is human blood, and a blood type may also be able to be determined, or possibly, a "fingerprint" of the blood may be determined through scientific examination (genetic). If the blood is the same type as the claimants, and if genetic testing can be performed, this may help to clear up any issues with regards to the whereabouts of the blood content. Common Scenario #1: Product liability claim. A claim is submitted whereby the claimant alleges that straight pins were in his Danish roll purchased at an insured grocery store. The claimant claims to have eaten or bitten into the roll, sustaining injury. In some cases, the claimant may have alleged to swallow the item. In cases such as this, the following recommendations should be considered: Index the claimant. If possible, examine the remains of the product (Danish roll) and note via examination and photographs the placement of any remaining pins in the Danish. The pins may be laying all in one direction, or may be lying in different directions. The pins may be in the icing, but not in the dough or vice versa. The pins may be examined, and depending on the material from which they are manufactured, may show evidence of neat demarcation as though the pins were in the Danish at the time the Danish was baked. In some

2 cases, the Danish may be adhered to the pins as though the ingredients were baked onto the pin. In other cases, the pins may appear shiny and clean. Consult with the insured to determine where they purchased the ingredients for the Danish roll. They may obtain the dough from a different manufacturer than where they obtain the icing. Because of these types of claims, many manufacturers run their icing and dough through metal detectors, which would detect any metallic foreign object. Obviously, this would be important from both a subrogation aspect as well as a liability aspect. Who mixes the ingredients to make the Danish roll and who bakes the roll? Consider visiting the insured's premises to photograph the ovens, trays, and handling methods of the Danish rolls to determine of any straight pins or any other metallic items discovered in the Danish roll are in the immediate vicinity of the kitchen/bakery. In taking the claimant's recorded statement, identify when the Danish was purchased? How it was bagged? What other items were purchased in the store (sometimes the claimant will have a receipt which should be reviewed to see if it notes the purchase of any straight pins)? Where the claimant went after leaving the store? How long after the purchase did the claimant eat the Danish roll? How many bites were taken before discovering the object? What injuries were sustained? When was initial medical treatment pursued? Were there any witnesses? Was more than one Danish roll purchased, and if so, did they eat the remaining Danish rolls or keep them as evidence? Have they ever had a product contamination claim before, and, did the previous claims have any similar circumstances to the one in question? Obtain a medical wage authorization to pursue applicable medical records and wage loss records. The initial medical records at the hospital will be important to determine the history as to whether the claimant swallowed the object, or sustained any actual oral injury. Were x-rays taken? Did x-rays show object? A neighborhood canvass could be conducted to determine if neighbors know of the incident, and a courthouse records check could also be conducted to determine if any previous suits exist concerning claims. Common Scenario #2: Product liability. The claimant reports an injury caused by the presence of an object in food which raises the concerns of communicable diseases. This would include: needles, blood, condoms, or other possible bodily fluids. Recommendations in a case such as this may include: Analysis of the manufacturing process of the product in which the item/contamination was allegedly found. For example, I am aware of claims where condoms have allegedly been found in milk cartons. However, the process at the manufacturing plant is a "closed" process, which prohibits anyone from placing a condom in the milk container during its manufacture or during the entry of the milk product. Examination of the condom may reveal a condom that is not damaged. The milk cartons are made with the application of high heat, which binds the carton together. The insured should be questioned as to whether this heat would have been sufficient to have caused the condom to melt or distort. Obviously, if the condom was in the carton during its manufacturing process, it would have been subjected to this heat level. Additionally, if the addition of the milk product is in a "closed" environment where no means of entry of the condom into the product can be made, this would certainly be an avenue of defense in such a case. An extensive history of the claimant with regards to medical doctor's records should be pursued to look for other documentation of product type claims and to look for the history of any injury alleged. In light of the fear of communicable diseases, such medical history may be important if, in fact, a person has been exposed to a virus that could pose a serious or deadly health risk. Could this exposure have occurred by other means according to the medical records?

3 FILE REVIEW TIPS When reviewing files to make recommendations, look for the following: Review for altered receipts, letters, prescriptions, etc. Look for treatment dates on medical bills that occur on a Saturday or Sunday. Look for conflicting treatment versus original claimed injury. i.e.: original claimed injury is a back injury, yet treatment is for a left knee. Review medical records for any indication of a subsequent injury, other accident. When copies of personal checks for baby-sitting, lawn care, and housekeeping, are made out to friends, check the date and check number for duplication. It has been my experience that when a significant number of checks have been photocopied and submitted out of order, that these checks may be duplicated. Review the file for inconsistencies in the stories between the insured, claimant, and witnesses. Review for malingering or exaggeration of injuries. Review the file for any claims history which has not been pursued reference the insured/claimant. Notice any different social security numbers used on the medical bills. Notice if the file warrants referral to the state fraud bureau or law enforcement. Review copies of applications for insurance to determine if any misrepresentations exist. accident was not caused by the accident, but was caused by medical malpractice. Ask yourself if all of the supporting documents have been secured with regards to verifying damages, if not, make recommendations to pursue the necessary documentation. When looking at multiple files involving the same medical practitioners, compare medical reports between each file for identical wording which may be indicative that the reports are "canned" which may necessitate an independent medical examination (IME). LIABILITY CLAIM INVESTIGATION TIPS In liability claims there are a wide variety of referrals you will receive such as: slip and fall claims, food tampering claims, and product liability claims such as chemical burns, product failure, etc. The investigations for all liability claims follow a similar path. The suggested steps below provide an overview of a liability claim investigation. Receive and review referral Conference with file handler to determine what value added services NICBI can provide. Outline investigation and potential time frames. Review claim file and investigation to date. Identify any inconsistencies, or red flag indicators, which should be explored. Conduct a database check on claimant to verify identity. (DIG)

4 Using all information obtained on claimant, conduct database checks with all names, addresses, ssn s, and common relatives or acquaintances identified. Obtain DMV ownership of vehicles and insurance information. Obtain driver s record of claimant and other drivers. If not represented, make contact with claimant. An unannounced face to face is preferred. If represented, contact attorney and arrange for recorded statement. Conduct complete and thorough interview to include: identification check, any other name used, name of any past treating doctor or facility, detailed description of current mechanism of accident, injury and pain at time of accident, current complaints of pain and injury, treating professionals and detailed description of treatment, identification of any witnesses, detailed description of any activities and limitations, previous injuries, previous accidents, previous insurance claims, loss of income. Obtain releases to include, medical, income/employment, financial, BMV, accident report. Verify claimed last wages with employer. Locate witnesses and obtain recorded statements. Verify witness statements. Take recorded statements from insured, passengers and other driver. Interview police officers and obtain police report and ambulance report. Accident scene investigation. Photos, Video, Diagram (check and see if the police took photographs). Verify all specials. Clinic Check, Track and verify all original documents. Check and see if treatment is in accordance with statutory requirements. Identify and locate previous medical records. Trace hospital search. Courthouse Checks and Background Checks. Contact other carriers if hits were received from Index Bureau check. Specialized Professionals (Engineers, Alarm Experts, Medical Experts, Accident Reconstruction, Handwriting Analysis, Medical Billing Analysis). Get IME if necessary. Identify any policy issues. On a slip and fall claim, verify constructive notice requirement. Did insured have notice of the hazard? Is the claimant s slip and fall incident due to an open and obvious hazard? Constructive Notice is the theory that a normal and prudent person must have knowledge on an existing hazard, then have an opportunity to alleviate the hazard, but fail to do so, in order to be responsible for a resulting injury. Investigative keys are: when the area was last inspected and by whom? Was the area inspected on a regular schedule? There is no hard and fast rule as to the frequency of inspection and what constitutes when a normal and prudent person should have been aware of a hazard. For instance, the time frame for inspections would differ based on what would be reasonable for the business involved, i.e.: a high volume grocery store would require more frequent floor inspections than a funeral home floor which has little people traffic. Identify any subrogation opportunities and refer to appropriate individual. Do Activity Checks/Surveillance if appropriate.

5 Neighborhood Check/Canvass. Assist defense attorneys with deposition and trail preparation. Referral to appropriate law enforcement agency. Note 1: In workers' compensation claims, liability claims, or any injury claim, requesting a driver s license record from the state can identify automobile accidents in which the claimant has been involved. If your state has such documentation, this can help to identify if the claimant's complaints or problems actually occurred as a result of an automobile accident versus the "slip and fall". Also inquire with the insured as to whether or not they have videotape for security which may have picked up the slip and fall by coincidence. Surveillance videotapes which were taken primarily for robbery purposes may turn out to be ideal evidence to either substantiate or refute a slip and fall claim. Note 2: In liability claims pay particular attention to claimants who give statements to the file handler which are detailed but their identities cannot be confirmed through standard practices. If a claimant cannot be easily and readily independently identified it should be considered a red flag which indicates further investigation is necessary. Note 3: It is imperative that all Investigators maintain an open-mind. Even a person who is known to have had many slip and falls in the past could still have a legitimate slip and fall claim in this particular incident. Each case must be investigated on its own merits.

6 FORMS The following forms are to be considered tools to assist you in your investigation. They are not checklists to be completed and they are not mandatory in any way. They are only one method of recording information obtained during your investigation. They are not meant to steer, guide or restrain your investigation in any way. Completion of the form does not necessarily indicate a comprehensive investigation has been conducted. Your investigative expertise and judgment is relied upon to determine what actions are necessary to ensure a thorough investigation is completed.

7 SUBJECT FACT SHEET VENDOR CLAIM # DOL DATE INVESTIGATOR INVESTIGATOR # BILL TO CLAIMS REPRESENTATIVE REPRESENTATIVE PHONE # INVESTIGATOR S PHONE # REPRESENTATIVE ADDRESS FAX # SUBJECT DOB ADDRESS PHONE # S,,, SSN # SEX RACE AGE HEIGHT WEIGHT NATIONALITY BUILD EYE COLOR HAIR COLOR STYLE/LENGHT GLASSES FACIAL HAIR MARKS, SCARS, TATOOS PHOTO IN FILE INJURIES CLASSIFIED ANY IME S OR HEARINGS PENDING DATE LOCATION LICENSE INFO: STATE CLASS EXPIRES SUS/REV ADDRESS ON LICENSE REGISTRATION: STATE PLATE # YEAR MAKE COLOR MODEL STATE PLATE # YEAR MAKE COLOR MODEL ADDITIONAL KNOWN ADDRESSES: ASSIGNMENT: ASSIGNED DATE TO NAME

8 PERSONAL CONTACT On,,, I contacted / was contacted by, address, phone # in reference to file. The following was discussed:

9 WITNESS STATEMENT/INTERVIEW FORM THIS INTERVIEW CONCERNS FILE # ; PLEASE STATE YOUR FULL LEGAL NAME FOR THE RECORD: ; AGE: ; DOB: ; SSN: ; HOME ADD.: ; CITY: ; ST.: ; ZIP: ; TELEPHONE NUMBER: ; WORK NUMBER: ; EMPLOYER: ADDRESS: ; POSITION: ; THIS INTERVIEW CONCERNS A (SLIP & FALL; WORK RELATED INJURY; AUTO ACCIDENT; ETC.) WHICH OCCURRED AT LOSS LOCATION) ON (DATE) AT APPROX.: AM--PM. IS THAT CORRECT: YES--NO; PLEASE DESCRIBE YOUR POSITION OR LOCATION (OBSERVATION POINT) IN RELATION TO THE INCIDENT: ; APPROX. HOW MANY (FEET--YARDS--CAR LENGTHS--ETC.) EXISTED BETWEEN YOUR LOCATION AND THE INCIDENT: ; DESCRIBE ANY OBSTRUCTIONS WHICH LIMITED YOUR VIEW OF THE INCIDENT: WERE YOU (SITTING, STANDING, ETC.) AT THE TIME YOU OBSERVED THE INCIDENT: ; WHAT WERE THE WEATHER CONDITIONS AT THE TIME: ; DID THE WEATHER CONDITIONS CONTRIBUTE TO THE (SLIP & FALL, AUTO ACCIDENT, WORK INJURY, ETC.): YES--NO; IF SO, PLEASE DESCRIBE HOW THE WEATHER CONTRIBUTED: ; PLEASE DESCRIBE IN DETAIL YOUR OBSERVATIONS OF THE INCIDENT:

10 IN YOUR OPINION, WHO DO YOU BELIEVE WAS AT FAULT FOR THIS INCIDENT: ; WHY: ; DO YOU KNOW ANY OF THE PARTIES TO THIS INCIDENT: YES--NO; IF SO, HOW DO YOU KNOW THESE INDIVIDUALS: DO YOU WEAR GLASSES OR CONTACTS: YES--NO; STRENGTH: ; DID YOU WEAR THE GLASSES/CONTACTS AT THE TIME OF YOUR OBSERVANCE: YES--NO; WERE THERE ANY OTHER PERSONS WITH YOU AT THE TIME OF YOUR OBSERVANCE: YES--NO; IF SO, WHO: (NAMES, ADDRESS, PHONE #, AGE): DID YOU DISCUSS YOUR OBSERVATIONS WITH THESE PERSONS: YES--NO; DID ANY OF THESE WITNESSES DESCRIBE THE INCIDENT DIFFERENTLY THAN YOU OBSERVED: YES--NO; IF SO, WHY: ; WERE THEIR OBSERVATION POINTS DIFFERENT THAN YOURS: YES--NO; DESCRIBE THE LOCATION OF EACH WITNESS: ; DESCRIBE ANY INJURIES YOU OBSERVED AT THE SCENE OF THE INCIDENT: WHAT TREATMENT WAS RENDERED AT THE SCENE: WHO TREATED THE INJURED: ;

11 WAS AN AMBULANCE CALLED: YES--NO; NAME OF AMBULANCE: ; POLICE: ; FIRE DEPT.: ; WERE ANY INJURED TRANSPORTED TO A HOSPITAL: YES--NO; IF SO, WHO: ; WHAT HOSPITAL: ; TRANSPORTED BY THE AMBULANCE OR CAR: ; DID YOU HEAR ANY COMMENTS MADE BY ANYONE INVOLVED IN THE INCIDENT REGARDING THE INJURIES OR LACK OF ANY INJURY: YES--NO; IF SO, WHO MADE THE COMMENTS AND WHAT WAS SAID: AT THE TIME OF YOUR OBSERVANCE, WERE YOU UNDER THE INFLUENCE OF ALCOHOL, ILLEGAL DRUGS, OR RX MEDICATION: YES--NO; IF SO, DESCRIBE: DID THIS IN ANY WAY AFFECT YOUR MENTAL ABILITY, JUDGMENT, OR IMPAIR YOUR ABILITY TO ACCURATELY OBSERVE THIS INCIDENT: YES--NO; WERE ANY VICTIM(S) OF THE INCIDENT, IN YOUR OPINION, UNDER THE INFLUENCE OF ALCOHOL, ILLEGAL DRUGS OR RX MEDICATION: YES--NO; IF SO, WHICH VICTIMS: ; FOR WHAT REASON(S) DID YOU BASE THAT OPINION: WERE ANY WITNESSES IMPAIRED AS A RESULT OF BEING UNDER THE INFLUENCE OF ALCOHOL, ILLEGAL DRUGS, OR MEDICATION: YES--NO; IF SO, WHO: ; REASON FOR THAT OBSERVANCE AND OPINION: