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WorkSafeBC

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Employer fraud allegation form

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

1. Employer information
Firm name
Doing business
as name
Firm address
Address (cont.)
City
 
Province
Postal code
Phone number
Owner's full name
 
2. Please provide the WCB Account number for this employer, if known:
 
WCB Account number
     
3.
Do you know of other physical locations for the firm?
No Yes – If yes, please list:
 
Location 1 address
 
City
 
Postal code
 
Location 2 address
 
City
 
Postal code
     
4. Describe the firm's business operations below:
 
   
5. Why have you reported this firm?
 
   
6. Does this firm have employees?
No Yes 		If yes, how many?
  Please list employees below (if known):
  Name Phone
  Address City
  Province Postal code
   
  Name Phone
  Address City
  Province Postal code
         
  Name Phone
  Address City
  Province Postal code
         
  Name Phone
  Address City
  Province Postal code
         
  Name Phone
  Address City
  Province Postal code
         
7. Please note any other information you have that may help us in our investigation.
 

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.

8. Do you wish to keep your name confidential?
Yes No
     
9. Can we contact you for further assistance should it be necessary (the investigator may develop further questions)?
Yes No
     
10. Your contact information:  
 
First name
Last name
Phone number(s)
E-mail
11. Can you provide any physical evidence of fraud? e.g. documents, letters, videotapes
  Yes No Possibly
   
12.

If yes or possibly, please describe the evidence: