Get CA DWC-AU-906 2013-2023

PRINT CLEAR AUDIT REFERRAL FORM Claims administrator / Company name Injured worker name Claim number City state ZIP Date of injury Date or period of violations Employer SPECIFIC DETAILS OF COMPLAINT Describe the nature of the complaint being as specific as possible. For example late payments of temporary or permanent disability the number of late payments if known failure to pay periods not paid if known failure to pay or object to medical treatment or medical-legal bills failure to investigate a claim unsupported denial of liability for a claim et al* Please attach copies of supporting documentation if available. Complainant name title Date Address city state ZIP DIR PRIVACY NOTICE The Department of Industrial Relations Division of Workers Compensation uses the information in your complaint 1 to monitor workers compensation claims administrators 2 to assist DWC and other government agencies in general civil and criminal law enforcement and 3 to conduct research on the workers compensation system* If you indicate that you want your complaint kept confidential the Audit Unit will not share your complaint with any party named in your complaint* If you do not request confidentiality the Audit Unit may share your complaint with the claims administrator. Please note that your complaint and your workers compensation claim information cannot be disclosed to the public under the Public Records Act. If you have questions about this notice please write to Privacy dir. ca*gov. DWC-AU-906 Rev* 06/13. For example late payments of temporary or permanent disability the number of late payments if known failure to pay periods not paid if known failure to pay or object to medical treatment or medical-legal bills failure to investigate a claim unsupported denial of liability for a claim et al* Please attach copies of supporting documentation if available. Complainant name title Date Address city state ZIP DIR PRIVACY NOTICE The Department of Industrial Relations Division of Workers Compensation uses the information in your complaint 1 to monitor workers compensation claims administrators 2 to assist DWC and other government agencies in general civil and criminal law enforcement and 3 to conduct research on the workers compensation system* If you indicate that you want your complaint kept confidential the Audit Unit will not share your complaint with any party named in your complaint* If you do not request confidentiality the Audit Unit may share your complaint with the claims administrator. Complainant name title Date Address city state ZIP DIR PRIVACY NOTICE The Department of Industrial Relations Division of Workers Compensation uses the information in your complaint 1 to monitor workers compensation claims administrators 2 to assist DWC and other government agencies in general civil and criminal law enforcement and 3 to conduct research on the workers compensation system* If you indicate that you want your complaint kept confidential the Audit Unit will not share your complaint with any party named in your complaint* If you do not request confidentiality the Audit Unit may share your complaint with the claims administrator. Please note that your complaint and your workers compensation claim information cannot be disclosed to the public under the Public Records Act. .