Report Unfair Benefits Fraud

Report an injured worker on benefits doing inappropriate physical activities

Do you wish to file a complaint with Washington States Department of Labor & Industries about an injured worker you believe is taking advantage of the workers' compensation system? Let us know by completing this form. We take action against fraud because it increases costs for everyone. Please provide as much information as you can. We will need it to pursue your complaint.

Injured Worker Information	* Required information
First Name:
Last Name:
Aliases or Other Names:
Street Address:
Address (cont.):
City, State, Zip +4	-- AA AE AK AL AP AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY    -
Work Phone: - include area code	000-000-0000
Home Phone: - include area code	000-000-0000
Previous address:
Date of Birth:
Known Hangouts:
Vehicle Description:	Make/Model/Year/Color
Physical Description of Injured Worker
Race:
Gender:	Male Female
Height:
Weight:
Approximate Age:
Facial Hair:	Beard Mustache
Allegation Information
* Allegation Summary: Please summarize your allegation.
Claim Number:
Did the alleged injury occur at all?	Yes No Unknown
Did the alleged injury occur on the job?	Yes No Unknown
If No, please describe how and where the injury occured:
Was medical treatment sought/received?	Yes No Unknown
If YES, provide name/city  of medical facility/provider:
Was a claim filed with a third party? (i.e. other insurance company)	Yes No Unknown
If YES, with whom?
Date of injury?
Were there any witnesses to this injury?	Yes No Unknown
If YES, please provide the  witness names(s), phone  number(s) and address:
Can you provide evidence of fraud?	Yes No Possibly
If YES or Possibly, please  describe the evidence.
Injured Worker Employment Information
Company Name:
Company Address:
Company Address (cont.)
City, State, Zip +4	-- AA AE AK AL AP AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY    -
Supervisor Name:
Supervisor Phone:	000-000-0000
Type of Employment: (i.e. construction, clerical, etc.)
Describe Job Duties:
Work Pattern:	Full-Time Part-Time As Needed Other
Work Hours:	Days Swing Graveyard Other
Is the worker being paid under the table?	Yes No Unknown
Is the worker related to the employer?	Yes No Unknown
If YES, describe the  relationship:
Currently working for this employer?	Yes No Unknown
Dates worked?
Other Injured Worker Information
Do you think the claimant is violent or may be a danger to an investigator?	Yes No Possibly
Is the claimant involved in any other type of fraudulent activity that you are aware of?	Yes No
Are you aware of any other people who have knowledge of the reported fraudulent behavior?	Yes No
If YES, please provide their  names, phone numbers, and  addresses (if known):
L&I may need to contact you to pursue this fraud complaint. If you can, complete the contact information below. Note: We are occasionally required by law to disclose contact information. If you include your personal contact information in this fraud report and wish to remain anonymous, read and answer the following statement: I am requesting the Washington State Department of Labor & Industries withhold disclosure of my identity regarding this fraud report because I fear disclosure would endanger life, physical safety, or property, pursuant to RCW 42.56.240(2). Yes No

Your Information
Your Name:
Your Daytime Phone: - include area code	000-000-0000
Your Evening Phone: - include area code	000-000-0000
Your Address:
City, State, Zip +4	-- AA AE AK AL AP AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY    -
Fax:
E-mail:
Relationship to claimant:

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