NYS Workers’ Compensation Board, Office of the Fraud Inspector General Employer Fraud Referral Form To report an employer that you suspect is violating the workers’ compensation coverage requirements, please complete this form. This information is confidential. Reason For Referral  No workers’ compensation coverage  Employer is underreporting or concealing payroll  Employer is misclassifying employees  Other Name of Employer:_____________________________________Phone_____________ Address:________________________________________________________________ Type of business:_________________________________________________________ Number of workers:_______________________________________________________ Do they do business under any other name? ___________________________________ Please be as specific as possible with information provided. Some examples of alleged violations include: 1) Employer has 5 workers framing a house and the employer does not have workers’ compensation. 2) Employer reports paying his/her workers $10.00 an hour to the insurance company or the employee leasing company, but also pays another $5.00 an hour in cash “off the books”. 3) Employer is paying all or some individuals in cash “off the books”. 4) Employer is an asbestos removal company but has reported all employees as clerical employees for workers’ compensation premium classification purposes. ______________________________________________________________________________________ Describe alleged fraudulent activity: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Optional Information Your Name: _________________________________________ Your Daytime Phone Number: _________________________________________ The Office of the Fraud Inspector General may contact you to clarify the information that was provided or to obtain additional information. You may also report fraud to the Inspector General’s Fraud Hotline, 1-888-363-6001. IG-2 (5-08) American LegalNet, Inc. www.FormsWorkflow.com