Free Fraud Complaint - New York

STATE OF NEW YORK WORKERS COMPENSATION BOARD FRAUD COMPLAINT
Date:__________________ To: Workers Compensation Fraud Inspector General, 20 Park Street, Albany New York 12207 Phone (518) 473-4839 Fax (518) 402-1059 Toll Free 1-888-363-6001 Complaint received from: Address: Tel. No.___________

Complaint taken by_____________________________________________________________________ (If applicable) Name Title/Dept. Tel. No. District Office: Complaint received via: [ ] Mail [ ] Telephone [ ] Voice Message [ ] Other

Complaint Concerns: [ ]Attorney/Lic. Rep. [ ] Carrier [ ] Claimant [ ] Employer [ ] Health Provider Name of person/firm complained of: _______________________________________________________ Address: Tel. No. ________________

Describe alleged fraudulent activity: (Please provide as much detail as possible; and include names, dates, documents and witnesses; attach further information, if necessary) _____________________________________________________________________________________ _____________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ _____________________________________________________________________________________ Claim Information Name of Claimant: ______________________________________________________________________ Address: ______________________________________________________________________________ WCB Case No: Social Security No.____________________________

Name of employer at time of injury: ________________________________________________________ Address: ______________________________________________________________________________ Name of Insurance Carrier: ________________________________________________________________ Address: ______________________________________________________________________________ Was claimant working while receiving benefits? [ ] Yes [ ] No. If yes, indicate: Name of Employer: _____________________________________________________________________ Address: Tel. No. ___________

Has any of this information been reported to any other law enforcement agency? If so, state agency, contact person and telephone.___________________________________________________________________ IG-1 (5-08)