North Dakota > Workers Comp
Fraud Investigation Referral SFN 52584 - North Dakota
| Fraud Investigation Referral Form. This is a North Dakota form and can be used in Workers Comp . |
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FRAUD INVESTIGATION REFERRAL WORKFORCE SAFETY & INSURANCE SPECIAL INVESTIGATION UNIT SFN 52584 (05/2003) WSI HelpLine 1-800-777-5033 Questions? Call us. Report Injuries Immediately. ND Fraud and Safety Hotline 1-800-243-3331 Report Fraud and Unsafe Work Conditions. 1600 EAST CENTURY AVENUE PO BOX 5599 BISMARCK ND 58506-5599 TELEPHONE NUMBER (701) 328-3800 TOLL FREE FAX NUMBER 1-888-786-8695 TDD NUMBER (for the hearing impaired only) (701) 328-3786 www.WorkforceSafety.com Mail completed form to: Special Investigations Unit Workforce Safety & Insurance P.O. Box 5599 Bismarck ND 58506-5599 Please use this form to report employer/business (include owner's full name), injured worker (employee), and provider workers' compensation fraud. All information on this form will be held in strict confidence by Workforce Safety & Insurance. INFORMATION ON REPORTED PARTY Date Name of employer/business (include owner's full name), injured worker, or provider Home number (if applicable) Address Work number City, State, Zip Why do you suspect that this employer/injured worker/provider is committing workers compensation fraud? Please provide the name(s), address(es), and telephone number(s) of witnesses or other individuals who may have information concerning the reported fraudulent activities. May a fraud investigator contact you at a later date: OPTIONAL Name Address Yes Phone number City, State, Zip No American LegalNet, Inc. www.FormsWorkflow.com
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