Employer fraud allegation form

Please provide as much information as possible. Leave blank if you do not have the answer.

Employer/Organization name

Doing business as name

Address

Phone number

Owner's name

WorkSafeBC account number

Claim number(s) and/or injured worker(s) name if known

Operating location(s) e.g. job sites, work location(s), etc.

Do they have employees and/or subcontractors (if known)

Yes No

If yes, please provide number (if known)

What is the nature of your concern(s) related to the employer?

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 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