STATE OF NEW YORK WORKERS' COMPENSATION FRAUD INSPECTOR GENERAL Empire State Plaza, Agency Building 2, 16th Floor Albany, NY 12223 Toll-free Hotline: 1-800-367-4448 Inspector.General@ig.ny.gov Fax: 518-486-3745 The person you are complaining about is a: Person collecting workers' compensation benefits Employer/Business Attorney/Licensed Representative Other workers' compensation fraud Health Provider/Facility Insurance Carrier If you believe a person who is seeking or receiving workers' compensation may be committing fraud: Name: Address: Name of insurance carrier: Was the person working while receiving benefits? Yes Name of employer at time of injury: No If Yes, where? Social Security No.: WCB Case No.: If you believe an employer or business is committing workers' compensation fraud: Name of employer or business: Type of business: Address of employer or business: No. of workers: Do they do business under any other name? Describe alleged fraudulent activity related to workers' compensation. Please provide as much detail as possible. You may provide further documentation if necessary. Has this information been reported to any other law enforcement agency? If yes, who? Your contact information: Name: Address: Telephone No. (area code): If you wish to file any other complaint regarding workers' compensation fraud, please call the Inspector General's toll-free hotline at 1-800-367-4448. This will put you in contact with trained staff who can discuss with you the specifics of your complaint. IG-1 (1-16) American LegalNet, Inc. www.FormsWorkFlow.com