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WorkSafeBC

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Claimant/worker fraud allegation form

Please provide as much information as possible. Write "unknown" if you do not know the answer.

1. Claimant/worker information
First name
Last name
Address
Address (cont.)
City
Province
Postal code
Work phone
Home phone
   
2. How do you know the worker is receiving WCB benefits?
   
3. Where and when did the alleged injury occur?
     
4. Claim number (if known):
     
5. Claimant/worker SIN (if known):
     
6. Claimant/worker date of birth or age:
     
7. Claimant/worker known hangouts (e.g. gyms, recreational spots):
   
8. Physical description of claimant/worker
Race
Gender
 Male Female
Height
Weight
Hair colour
Eye colour
Scars/tattoos
Facial hair
 Beard Mustache
Glasses
 Yes No
   

9.

 Vehicle description
 

Vehicle – make/model, year, colour, license plate
   

10.

 Work/employment information
Company name
Street address
Address (cont.)
City
Province
Postal code
Work phone
Supervisor name
Supervisor phone
   
11. Type of employment (i.e. construction, clerical, nursing, etc.):
   
12.

Work pattern:
Full-time
Part-time
   
As needed
Other
      Describe
       
13.

Work hours:
Days
Swing
   
Night
Other
      Describe
       
14. Is the worker being paid "under the table"? Yes No Unknown
     
15. Is the worker related to the employer? Yes No Unknown
     
16. If yes, describe the relationship:
     
17. Currently working for this employer? Yes No
     
18. Dates worked:
     
19. Inappropriate physical activity
  Describe the inappropriate physical activity:
  When, where and how often does this activity take place?
  How long has the claimant/worker been engaging in this activity?
  Does the activity change when the claimant/worker is meeting with doctors, vocational counselors, etc? Yes No Unknown
  Do you know of any other witnesses to this activity? Yes No Unknown
  Can you provide their name, address, and phone number?
   
20. Do you feel the claimant is violent or may be a danger to an investigator?
Yes No Possibly Unknown
   
21.

Is the claimant involved in any other type of fraudulent activity that you are aware of?
Yes No Possibly Unknown
   
22. What prompted you to contact us?
   
23. Is there anything else you would like to add?
 
24. Source information
  Thank you for the information you have provided. It will be helpful if you leave your name and phone number in case we need further assistance. We will investigate this information whether you provide your name or remain anonymous.
  Do you want to keep your name confidential? Yes No
  Can we contact you for further assistance should it be necessary? (the investigator may have further questions) Yes No
     
25. Provide this information:  
 
First name
Last name
Contact phone number(s)
E-mail
   

26.

 Can you provide any physical evidence of fraud? e.g. documents, letters, videotapes
  Yes No Possibly
   
27.

If yes or possibly, please describe the evidence: