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Report suspected fraud
Service provider fraud allegation form

Service provider fraud allegation form

Please provide as much information as possible. Leave blank if you do not have the answer.

Service provider information

Thank you for the information you have provided. It will be helpful if you leave your name and phone number in case we need further assistance. We will investigate this information whether you provide your name or remain anonymous.

First name

Last name

Service provider business/clinic name:

Address

Phone number

Owner’s name

What types of goods and/or services do they provide?

Claim number(s) and/or injured worker(s) name (if known)

Areas of concern

What are your concerns related to this matter?

How did you become aware of this information?

Do you have other information such as names of witnesses, social media accounts, email address, etc.?

If yes, please provide the information below.

Contact information

Please provide us your name, phone number, and/or email in case we need to contact you for further information

First name

Last name

Phone number(s)

Do you wish to keep your name confidential?

Yes No