Workers’ Compensation Fraud

Please fill out the form below to report Workers’ Compensation Fraud

Type of fraud being reported: *
Choose one type of fraud

Tell us about yourself

Please provide your contact information.

First Name
Last Name
Date of Birth
Email Address
Phone Number
Address
Apt/Suite
City
Zip Code

Employer

Please provide the employer details

Employer Name
Employer Address
Apt/Suite
City
Zip Code

Complaint

Tell us about the fraud

Have you reported this before?
Please provide a summary of events you want to report.

Notice: Please provide as much information as possible. Failure to provide sufficient information could prevent or delay the investigation of this complaint. You may remain anonymous; however, your contact information may be necessary to fully investigate this complaint.