Report Employer Premium Fraud in Washington State

Report Employer Premium Fraud in Washington State


Do you wish to file a complaint with L&I about an employer you believe is taking advantage of the Washington State workers' compensation system? Let us know by completing this form. We take action against fraud because it increases costs for everyone. Provide as much information as you can. We will need it to pursue your complaint.


Your Information

L&I may need to contact you to pursue this fraud complaint.  If you can, complete the contact information below.
Note: We are occasionally required by law to disclose contact information.   If you include your personal contact information in this fraud report and wish to remain anonymous, read and answer the following statement:
I am requesting the Washington State Department of Labor and Industries to withhold disclosure of my identity regarding this fraud report because I fear disclosure would endanger life, physical safety, or property, pursuant to RCW 42.56.240(2).

Do you wish to remain anonymous?




Your name: First: Last:
Your daytime phone:
- include area code
000-000-0000
Your evening phone:
- include area code
000-000-0000
Your address:
City, State, Zip +4:     - 
E-mail:
Information about employer you are reporting * Required information
Business name:*
Business address:
City, State, Zip +4:     -    
Business phone:
- include area code
000-000-0000
Principal owner name: First:    Last:
UBI number: (9-digit number, format: 999999999)
Contractor registration number:
What fraud are you reporting? *



Explain the reason for reporting fraud:
*
Worker Information
Number of workers:  
Do you have information about workers?

(Examples: names, contact phone numbers, SSN, length of employment, e-mail addresses, web sites, license plate numbers, etc.)

Yes No
General Contractor Information
Do you have information about who they work for?
(Examples: general contractor name, prime contractor names, phone numbers, etc.)
Yes No
Other Business Locations
Do you have information about any other business locations or site addresses?
(Examples: addresses, phone numbers, other contact names, directions, landmarks, etc.)
Yes No
Work Activities / Other Information
Can you describe the business work activities?
Yes No
Do you have other information to share?
(Examples: Your preferred method of contact, alternative contact information, other observations, etc.)
Yes No
When did you observe fraud?        MM/DD/YYYY
Do you know of any hazards that we should be aware of?
(Examples: Hazardous materials, safety comments for auditor, unsafe workplace, etc.)
Yes No
Electronic / Non-electronic Documents
Do you have documents available?
Yes No
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