| North Dakota Workforce Safety & Insurance

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Name of employer/business (include owner's full name), injured worker, or provider

Home Number

Work Number

Address

City/Town

State/Province

ZIP/Postal Code

Why do you suspect that this employer/injured worker/provider is committing workers' compensation fraud?

Please provide the name(s), address(es), and telephone numbers of witnesses or other individuals who may have information concerning the reported fraudulent activities.

May a fraud investigator contact you at a later date?

Yes

Investigator Contact

Please provide your information below so we may contact you to acquire additional information. We will maintain your anonymity.

Name

Phone Number

Email Address

City/Town

State/Province

ZIP/Postal Code

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Fraud Investigation Referral