Report Employer Premium Fraud in Washington State


Do you wish to file a complaint with L&I about an employer you believe is taking advantage of the Washington State workers' compensation system? Let us know by completing this form. We take action against fraud because it increases costs for everyone. Provide as much information as you can. We will need it to pursue your complaint.


Your Information

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 and select Option 2.



Your name: First: Last:
Your daytime phone:
- include area code 		000-000-0000
Your evening phone:
- include area code		 000-000-0000
Your address:
City, State, Zip +4:     - 
E-mail:
Information about employer you are reporting * Required information
Business name:*
Business address:
City, State, Zip +4:     -    
Business phone:
- include area code		 000-000-0000
Principal owner name: First:    Last:
UBI number: (9-digits, format: 123456789 or A12345678)
Contractor registration number:
What fraud are you reporting? *



Explain the reason for reporting fraud:
*
Worker Information
Number of workers:  
Do you have information about workers?

(Examples: names, contact phone numbers, SSN, length of employment, e-mail addresses, web sites, license plate numbers, etc.)
Yes No
General Contractor Information
Do you have information about who they work for?
(Examples: general contractor name, prime contractor names, phone numbers, etc.)
Yes No
Other Business Locations
Do you have information about any other business locations or site addresses?
(Examples: addresses, phone numbers, other contact names, directions, landmarks, etc.)
Yes No
Work Activities / Other Information
Can you describe the business work activities?
Yes No
Do you have other information to share?
(Examples: Your preferred method of contact, alternative contact information, other observations, etc.)
Yes No
When did you observe fraud?        MM/DD/YYYY
Do you know of any hazards that we should be aware of?
(Examples: Hazardous materials, safety comments for auditor, unsafe workplace, etc.)
Yes No
Electronic / Non-electronic Documents
Do you have documents available?
Yes No
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