Claimant/worker fraud allegation form

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

Worker's first name

Worker's last name

Worker's address

Worker's phone numbers

Claim number (if known)

Type of Injury

Age (date of birth if known)

Known hangouts (e.g. gyms, recreational spots, etc.)

Gender

Other physical identifiers (e.g. tattoos, glasses, scars, etc.)

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

Company name

Company's address

Type of employment (i.e. construction, clerical, nursing, etc.)

Does the worker have a relationship with the employer?

If yes, describe the relationship

Currently working for this employer?

Dates worked (if known)

What are your concerns related to this worker?

How did you become aware of this information?

Do you have other information such as names of witnesses, social media accounts, email address, etc.?

If yes, please provide the information below.

Please provide us your name, phone number, and/or email in case we need to contact you for further information

First name

Last name

Phone number

Do you wish to keep your name confidential?

Yes No