Worker's Compensation Fraud Allegation

* NOTE: Providing your name, phone number and email address are optional, but very helful. You may remain anonymous by not completing those items.

* Your name, phone and email:

Please provide any known information on the alleged fraudulent case below:

To be sure that we are able to adequately investigate your allegation, be sure to include as much of the following information as possible. If you do not know the answer,don't worry; just tell us what you do know.

Fraud Allegation Information:

** NOTE: Who is commiting fraud? and What are they doing? : fields are required.