CHP Public Forms

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 Investigations Unit (WCFIU) is a specialized team who investigate allegations of workers’ compensation fraud. 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.

* = Required Field

Section I - Referring Party

(if you wish to remain anonymous,please skip to Section II)

Name

Address

City

State

Zip Code

Minimum of 5 characters

Email Address

Contact Person and Phone Number

Your Telephone

Minimum of 10 characters

May we contact you?

Section II - Employee's Identification

* Employee's Name

Employee's Job Title

Employee's Age

Date of injury (if known) (mm/dd/yyyy)

Type of injury (if known)

Employee's Address

City

State

Employee's Zip Code

Minimum of 5 characters

Section III - Description of Alleged Fraud

Description of Alleged Fraud

Please describe your observations and other facts that lead you to believe the employee may be committing workers' comp fraud.

Section IV - Time Period of Alleged Fraud Activity

* From (mm/dd/yyyy)

* To (mm/dd/yyyy)

Section V - Activities

Is the employee physically active?

Yes
No
Do Not Know

Description of Physical Activity

If yes, describe the employee's routine, daily schedule, places they frequent, etc.