Workers’ Compensation Fraud Report Form
Report suspected workers’ compensation fraud by providing the details, people involved, and any supporting evidence you have.
Reporter Information
Full Name
*
First Name
Middle Name
Last Name
Role or Relationship to the Case
*
Please Select
Employee
Supervisor
Coworker
Insurer Representative
Third Party
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
*
Phone
Email
Either
Claim and Employer Details
Employer or Business Name
*
Claim Number (if known)
Injury Date (if known)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Report Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Job Site / Location of Incident
*
State or Region
Suspected Fraud Details
Types of Suspected Fraud
*
Exaggerated injury
Staged accident
Working while receiving benefits
False claim details
Falsified medical information
Misrepresented employment status
Other
Describe What Was Observed
*
Why This Appears Suspicious
People Involved and Witnesses
Claimant Name
First Name
Middle Name
Last Name
Role in Incident
Please Select
Claimant
Supervisor
Coworker
Manager
HR Representative
Other
Witness Name
First Name
Middle Name
Last Name
Witness Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Evidence and Supporting Information
Types of Evidence Provided
*
Photos
Documents
Emails
Messages
Videos
Records
Other
Upload Supporting Evidence
Upload a File
Drag and drop files here
Choose a file
Cancel
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Source of Evidence and Supporting Facts
*
Prior Reports and Follow-Up
Has this concern been reported before?
*
Yes
No
Not sure
Who was it reported to?
Outcome or current status, if known
Additional comments
Submit Report
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