New York > Workers Compensation
Fraud Complaint IG-1 - New York
| Fraud Complaint Form. This is a New York form and can be used in Workers Compensation . |
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STATE OF NEW YORK WORKERS' COMPENSATION BOARD FRAUD COMPLAINT Date: To: Workers' Compensation Fraud Inspector General, 20 Park Street, Albany, NY 12207 Complaint received from: Address: Complaint taken by: (If applicable) District Office: Name Tel. No. Name Title/Dept. Complaint received via: [ ] Mail [ ] Telephone Tel. No. [ ] 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: Name of employer at time of injury: Address: Name of Insurance Carrier: Address: Was claimant working while receiving benefits? Name of Employer: Address: Has any of this information been reported to any other law enforcement agency? If so, state agency, contact person and telephone. [ ] Yes [ ] No. If yes, indicate: Social Security No: IG-1 (1-97) American LegalNet, Inc. www.USCourtForms.com
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