| North Dakota Workforce Safety & Insurance

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?

If you would like a fraud investigator to follow up with you, please provide your contact information below. You can also choose to remain anonymous.

Yes

Keep my identity confidential (do not include my information in reports)

*If you do not select this option, your name may be included in reports.

Name

Phone

City/Town

State/Province

ZIP/Postal Code

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Fraud Investigation Referral