Complete this form to report a person you suspect of committing fraud against the workers' compensation system.
About the person you want to report
Known physical characteristics of the person you are reporting
Feet
Inches
Pounds
Hair color, eye color, tattoos, piercings, scars, birthmarks, mustache, etc.
Known addresses of the person you are reporting
Please select the address type above to add another address
Known phone numbers of the person you are reporting
Please select the phone type above to add another phone
Known online places of the person you are reporting
Provide as many email addresses as possible, separated by commas
Facebook, Twitter, Craigslist, Skill or Chore Service Exchange, etc.
Known places we can find the person you are reporting
Work places, addresses of family or friends, after hours hangout, etc.
Please include Other state and/or International in the Description field
Examples: Make, model, year, color, times and locations used, etc.
Please enter the license plate number above to add another vehicle
Known safety concerns when contacting the person you are reporting
Tell us how they are or could be violent. Do they have any weapons? Is there drug use?
Evidence and documentation that you want to share
Upload photos, videos, and documents.
Maximum file size: 20 MB
A maximum of (5) files can be uploaded with this submission.
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Uploaded Files (5 Available Uploads Remaining)
Do you have additional information about the person you are reporting?
I have information about the injury and/or workers' comp claim
Who were they working for at the time of claimed injury? Where were they working when the injury occurred? Tell us about any witnesses to the injury.
Month, day, year, if known, or estimate
Tell us more about what you know. Dates, times, locations, etc.
Name of hospital, clinic, doctor, etc.
Tell us more about what you know
I know about activities that the person should not be doing while injured.
Fishing, hunting, hobbies, auto mechanics, etc. How often? Where is this happening?
Are they in jail or prison? Have they seen multiple doctors for the same injury? Are they claiming a spouse and they're not married, or claiming dependents?
I know the person is working or has a business.
Where are they working?
Construction, online, etc.
Full time, part time, swing shift, etc.
How did you find out about this?
Please enter the company name above to add another job
What business are they running?
Construction, online, etc.
Provide as many names as possible, separated by commas
Bulletin boards, online, Craig's list, etc.
How did you find out about this?
Please enter the company name above to add another business
Your information
Important
Select 'Yes' if you prefer to remain anonymous. If you prefer to remain anonymous, but have additional information to share with L&I, submit this form and note the referral number.
Select 'No' to provide your contact information. If you do provide your name and contact information, under Washington's Public Records Act, L&I must provide it to anyone requesting it related to this form.
Please select the phone type above to add another phone