Workers' Compensation Fraud Reporting Form

Employee safety has always been a top priority for the California Highway Patrol (CHP), but accidents do happen and injuries do occur. The workers' compensation and disability retirement programs of the CHP are founded on the basic principle that any employee injured as a result of, or during the course of their employment, should be provided medical care and benefits while they recover; and, when the injury or injuries permanently prevent them from performing their duties, allows them to retire with specified benefits and compensation. When injuries occur, our obligation is to ensure all appropriate benefits are accessed and received by those injured employees. At the same time, it is crucial that we have policies and procedures in place to minimize the opportunity to take unfair advantage of the system or to commit outright fraud.

The CHP's Workers' Compensation Fraud Section (WCFS) is a specialized team of criminal investigators that investigate allegations of workers. compensation fraud by departmental employees. We receive information from a variety of sources, including our toll-free Fraud Reporting Hotline (1-866-779-9237), as well as this website. (For non-CHP employees, please click here).

If you have reason to believe someone is committing workers' compensation fraud, we encourage you to fill out the form below. We follow-up on every lead provided to us, so please include as much information as possible. You may fill in this form anonymously, or provide your name and telephone number so we may contact you for further information.

I. Referring Party		(if you wish to remain anonymous, please skip to Section II)
	Name:
	Address:
	City:
	State:	Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
	Zip Code:
	Email Address:
	Contact Person and Phone Number
	Your Telephone:
	May we contact you?	Yes No
II. Employee's Identification
	Employee's Name:
	Employee's Job Title:
	Employee's Age:
	Date of Injury (if known)
	Type of Injury (if known)
	Employee's Address
	City:
	State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
	Zip Code:
III. Description of Alleged Fraud
	Please describe your observations and other facts that lead you to believe the employee may be committing workers' comp fraud.
IV. Time Period of Alleged Fraud Activity
	From:
	To:
V. Activities
	Is the employee physically active? yes no do not know
	If yes, describe the employee's routine, daily schedule, places they frequent, etc.
		Enter the letters to the left in the field below, then press the "Submit" button.