Report Claim Fraud

Report claim fraud: Not injured at work or not injured at all

Do you wish to file a complaint with Washington State's 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    -
Work Phone:
- include area code

Home Phone:
- include area code

Previous address:
Date of Birth:
Known Hangouts:
Vehicle Description:
Physical Description of Injured Worker
Male Female  
  Approximate Age:
  Facial Hair:
Allegation Information
Allegation Summary:
Please summarize your allegation.
Claim Number:
Did the alleged injury occur at all?
Yes No Unknown
Was medical treatment sought/received?
Yes No Unknown
Was a claim filed with a third party? (i.e. other insurance company)
Yes No Unknown
Date of injury?
Were there any witnesses to this injury?
Yes No Unknown
Can you provide evidence of fraud?
Yes No Possibly
Injured Worker Employment Information
Company Name:
Company Address:
Company Address (cont.)
City, State, Zip +4    -
Supervisor Name:
Supervisor Phone:
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
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    
L&I may receive a request for public records under Washington’s Public Records Act for records relating to your complaint. If you include your name and contact information in your complaint, we will need to disclose it to the person requesting the complaint records. If you prefer not to share your contact information but would like to share additional information with the department about this complaint, please note the referral number and call 1-888-811-5974 (Select Option "3").
Your Information
Your Name:
Your Daytime Phone:
- include area code

Your Evening Phone:
- include area code

Your Address:
City, State, Zip +4    -
Relationship to claimant:
How did you learn about this referral page. Please select from the following:
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