Washington > Workers Comp > Fraud And Discrimination Reporting
Industrial Insurance Discrimination Complaint F262-009-000 - Washington
| Industrial Insurance Discrimination Complaint Form. This is a Washington form and can be used in Fraud And Discrimination Reporting Workers Comp . |
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Department of Labor and Industries Investigations PO Box 44277 Olympia WA 98504-4277 INDUSTRIAL INSURANCE DISCRIMINATION COMPLAINT Case Number (dept. use only) Complainants' full name: (your full name) Present address: Phone number: Job title: Will you need an Interpreter? Business name: Address: Did you report your injury to the employer? Date reported_________________ Yes Cell phone number: City: Date of birth: State: Date: Zip: Date of injury: Yes No Injury claim number: How long worked for employer? Yes No Do you speak English? What is the native language that you speak? Supervisor name: City: No State: Phone number: Zip: Name and title of person you reported the injury? Date of alleged act of discrimination: ____________ Action taken by Employer: Do you have an Attorney representing you with this complaint? Yes No Address: Name of Attorney: City: State: Phone number: Zip: Are you still employed with this employer? Yes No Date last worked _______________ Are you presently on light duty/restrictions? Are you released to work at this time? Yes No Full duty Light duty Was your employment terminated? Yes No Date of termination: _____________________ Yes No Dates from when to when: _________________ Date you Returned to Anticipated release for work date: work: Describe how you were discriminated against: (If you need more space to write, attach extra page(s)). F262-009-000 Industrial Insurance Discrimination Complaint 5/2012 American LegalNet, Inc. www.FormsWorkFlow.com Why did the employer take this action (in your opinion)? (If you need more space to write, attach extra page(s)). Have you filed your complaint with another agency? If so, which agency have you contacted? Yes No List the names, addresses and phone numbers of witnesses to the alleged acts of discrimination. I certify under the penalties of perjury that the information provided herein is the truth to the best of my knowledge. Date: Print name: Mail completed form to: Signature: Department of Labor and Industries Investigations PO Box 44277 Olympia WA 98504-4277 Your rights are: RCW 51.48.025 Retaliation by employer prohibited Investigation - Remedies 1) No employer may discharge or in any manner discriminate against any employee because such employee has filed or communicated to the employer an intent to file a claim for compensation or exercise any rights provided under this title. However, nothing in this section prevents an employer from taking any action against a worker for other reasons including, but not limited to, the worker's failure to observe health or safety standards adopted by the employer, or the frequency or nature of the worker's job-related accidents. 2) Any employee who believes that he or she has been discharged or otherwise discriminated against by an employer in violation of this section may file a complaint with the director alleging discrimination within ninety days of the date of the alleged violation. Upon receipt of such complaint, the director shall cause an investigation to be made, as the director deems appropriate. Within ninety days of the receipt of a complaint filed under this section, the director shall notify the complainant of his or her determination. If upon such investigation, it is determined that this section has been violated, the director shall bring an action in the superior court of the county in which the violation is alleged to have occurred. 3) If the director determines that this section has not been violated, the employee may institute the action on his or her own behalf. In any action brought under this section, the superior court shall have jurisdiction, for cause shown, to restrain violations of subsection (1) of this section and to order all appropriate relief including rehiring or reinstatement of the employee with back pay. F262-009-000 Industrial Insurance Discrimination Complaint 5/2012 American LegalNet, Inc. www.FormsWorkFlow.com
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