Free State of Vermont - Vermont

VERMONT

State of Vermont Department of Labor Workers' Compensation and Safety Division 5 Green Mountain Drive P.O. Box 488 Montpelier, VT 05601-0488 Report of Suspected Workers' Compensation Insurance Fraud

Suspected fraud by

an employee (obtaining benefits by willful false representation) an employer (obtaining lower premiums by willful false representation or misclassification) other: Please describe below

Person or Business Suspected of Committing Fraud

Name Phone Number Physical Address Mailing Address Email Address/Web Page
Employee Information Date of Injury Injury Description Employer At Time of Injury Date of Birth Employer Information Person's Position in the Business Type of Business Number of Employees Workers' Compensation Insurer Describe the suspected fraud; attach additional page(s) if necessary, and attach any relevant documentation*

Have you notified the insurance carrier that you suspect fraud in this matter?

Yes

No

In order for us to follow up with you, please provide the following information. This information is not confidential and may be released under certain circumstances. Your Name Phone Number Mailing Address E-mail Address Date of this report Your Relationship to the Person Suspected of Committing Fraud: Coworker Other Employee Former Employee Competitor Neighbor Family

Please return the completed form to the mailing address above, or by FAX to (802) 828-2195
*please refer to supplemental page/reverse side for additional information and suggestions SUSPECTED WORKERS' COMPENSATION FRAUD--SUPPLEMENTAL INFORMATION

VERMONT STATUTES 21 V.S.A. §708 Penalty for False Representation A person who willfully makes a false statement or representation, for the purpose of obtaining any benefit or payment under the provisions of this chapter, either for her or himself or for any other person, after notice and opportunity for hearing may be assessed an administrative penalty of not more than $5,000.00 total, and shall forfeit all or a portion of any right to compensation under the provisions of this chapter, as determined to be appropriate by the commissioner after a determination by the commissioner that the person has willfully made a false statement or representation of material fact. (b) An employer who willfully makes a false statement or representation for the purpose of obtaining a lower workers' compensation premium, after notice and opportunity for hearing before the commissioner of banking, insurance, securities and health care administration, may be assessed an administrative penalty of not more than $5,000.00 in addition to any other appropriate penalty. Examples of workers' compensation insurance fraud Employer: An employer intentionally under-reports payroll or intentionally misclassifies an employee as an "independent contractor" or "subcontractor" in order to lower the workers' compensation insurance premium. Employee: An injured worker earns wages while receiving Temporary Total Disability (TTD) benefits. When asked by the claim adjuster or doctor is s/he is working, the injured worker denies it. Adjuster: An insurance adjuster intentionally misinforms a company physician that an injured worker has a prior history of the current medical problem. Physician: A doctor treats a patient for an injury. The patient has no health insurance coverage. The patient does not indicate that work caused the injury but the doctor states in the record that work caused the injury in order to ensure bill payment. (a)

It is necessary for all elements to be met in order for an action to rise to the level of "fraud". Your complaint should address all the elements of the law:
Willful False Statement or representation Material fact For the purpose of Obtaining workers' compensation benefit for self or other means means means means means means intentional, deliberate; not inadvertent untrue written, spoken, action significant or essential to the matter at hand motivating reason intended outcome

DESCRIBE: What is the statement? Who made it? How was the false statement given--written, spoken, action--when, and to whom? Why is it false? Why do you suspect the false statement was intentional and deliberate? Could the statement have been inadvertent? Was the false statement given to obtain benefits or a lower premium ­ how do you know? How is this false information important? ATTACH RELEVANT DOCUMENTATION AND INFORMATION, SUCH AS Identification and contact information for subjects, witnesses, others who may have information Witness statements, investigative reports, surveillance reports, recorded statements, affidavits, video First Report of Injury, accident reports, wage statements, employee earnings reports, job search logs Report of indemnity, medical, permanency, other benefits paid, amount(s) and date(s) Medical documentation, activity restrictions, removal from work, statements to medical providers Communications between adjuster and claimant Insurance coverage documents and reports, classification statements Legal counsel name, address and telephone number