Fraud Investigation Referral
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Fraud Investigation Referral Form. This is a North Dakota form and can be use in Workers Comp.
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Tags: Fraud Investigation Referral, SFN 52584, North Dakota Workers Comp,
FRAUD INVESTIGATION REFERRAL SPECIAL INVESTIGATIONS UNIT SFN 52584 (10/2014) 1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 TELEPHONE 1-800-777-5033 Toll Free Fax 1-888-786-8695 TTY (hearing impaired) 1-800-366-6888 Fraud and Safety Hotline 1-800-243-3331 www.WorkforceSafety.com Mail completed form to Special Investigations Unit Workforce Safety & Insurance PO Box 5585 Bismarck ND 58506-5585 Please use this form to report employer/business (include owner's full name), injured worker (employee), and provider workers' compensation fraud. All information on this form will be held in strict confidence by Workforce Safety & Insurance. Information on reported party Date Home number (if applicable) Address City State ZIP code Name of employer/business (include owner's full name), injured worker, or provider Work number Why do you suspect that this employer, injured worker or provider is committing workers' compensation fraud? Please provide the name(s), address(es), and telephone number(s) of witnesses or other individuals who may have information concerning the reported fraudulent activities. May a fraud investigator contact you at a later date? Yes No Optional Name Address City State ZIP code Telephone Number American LegalNet, Inc. www.FormsWorkFlow.com
