Report of Possible
Fraudulent Activity
 

 

Please complete the following information to report possible fraudulent activity to Delta Dental, and we will investigate and determine if fraud has occurred.

Required fields are indicated by an asterisk *
A. *Description
of activity
 
B.*Name of individual(s) involved, if known

Name(s)*

Address/location*

Telephone number*
- -

 

C. Other additional information that might be useful in pursuing this matter

(Optional)

Your Name

E-mail address

Telephone number
- -