KANSAS DEPARTMENT OF LABOR www.dol.ks.gov REPORT OF FRAUD OR ABUSE (CONFIDENTIAL) K-WC 44 (3-14) MAIL: Division of Workers Compensation 401 SW Topeka Blvd., Suite 2 Topeka, KS 66603-3105 FAX: (785) 296-7710 NOTE: You may choose to submit this form anonymously; however, this may limit the scope of the investigation. Date of report: ________________ Your name: _______________________________________ SSN: _________________ Date of birth: _____________ Street: __________________________________ City: ______________________ State: _______ ZIP: _____________ ( ) Phone: _______________________________________ Email: ______________________________________________ Name of person or entity suspected of committing fraud or abuse: ________________________________________ Street: __________________________________ City: ______________________ State: _______ ZIP: _____________ ( ) Phone: _______________________________________ Email: ______________________________________________ Identifying information if applicable and available (not required): SSN: ________________ Date of birth: _____________ Driver's license: _________________________ Other (e.g., FEIN, etc.): _______________________________________ Name of person or entity the fraud or abuse was committed against: ______________________________________ Street: __________________________________ City: ______________________ State: _______ ZIP: _____________ ( ) Phone: _______________________________________ Email: ______________________________________________ Identifying information if applicable and available (not required): SSN: ________________ Date of birth: _____________ Driver's license: _________________________ Other (e.g., FEIN, etc.): _______________________________________ County in which the accidental injury, repetitive trauma or occupational disease occurred: __________________________ Date(s) on which the accidental injury, repetitive trauma or occupational disease occurred: _________________________ _________________________________________________________________________________________________ Give details below of the fraudulent or abusive act(s). Attach additional pages if necessary. Supporting documentation: Attached Can submit upon request DIVISION OF WORKERS COMPENSATION 401 SW Topeka Blvd., Suite 2, Topeka, KS 66603-3105 � Phone: (785) 296-4000 (opt. 4) � Toll Free (800) 332-0353 (opt. 3) � Fax: (785) 296-7710 American LegalNet, Inc. www.FormsWorkFlow.com