Get Wc Fraud Intake Form

Filing a complaint can be a crucial step in addressing concerns related to worker’s compensation fraud. This guide provides a clear and supportive overview of how to effectively complete the WC Fraud Intake Form online, ensuring that your submission is thorough and accurate.

Follow the steps to complete the form with ease.

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. In the section labeled 'Complaint is against,' provide the name of the individual or entity you are reporting.
3. For 'Complaint involves,' detail the specific aspects of the situation or behavior that you believe constitutes fraud.
4. In the 'Alleged suspect' field, enter the name of the person you believe is committing the fraudulent act.
5. In the 'Alleged victim' field, if applicable, provide the name of the person who is affected by the alleged fraud.
6. Fill in the 'Name' section with your personal details, including your full name.
7. Provide the 'Employer name' associated with the alleged suspect.
8. Complete the 'DOB' field with your date of birth to verify your identity.
9. Enter your Social Security Number in the 'SS#' section for identification purposes.
10. Fill in your current address using the 'Address' section.
11. Provide your phone numbers, including home and cell phone numbers, in the respective fields.
12. In the 'Carrier' section, enter the insurance carrier’s name related to the claim.
13. Fill in the 'Carrier Claim#' with the relevant claim number assigned by the insurance.
14. Include your email address in the designated field for further communication.
15. Provide your 'WC#'—the worker's compensation number if applicable.
16. In the 'DOI' field, enter the date of incident related to the alleged fraud.
17. In the 'Complainant’s statement with details of alleged offense,' provide a detailed account of the alleged fraudulent behavior.
18. List any witnesses who can verify your claims in the specified section. Include their contact information and be specific about their knowledge of the incident.
19. Complete your information under 'Complainant’s information' including your name, choice of anonymity, address, and contact numbers.
20. Finally, after reviewing the completed form for accuracy, save your changes, download a copy, print, or share the form as necessary.

Get started on completing your WC Fraud Intake Form online today!