Oklahoma Attorney General's Office
Worker's Compensation and Insurance Fraud Unit Complaint Form


Your Information
1.First Name:
Middle Initial:
Last Name:
Street Address:
City:
State:
Zip:
Home Phone:
Work Phone:
E-Mail Address:


Business or Individual Complained Against
2.Business or Last Name:
Individuals First Name:-
Street Address:
City:
State:
Zip:
Phone:
SSN:
DOB:

3.If an individual, please state name, address and phone number of his or her employment:
4.Is there a case pending with the Workers' Compensation Court (if applicable)?

Case Number:

5.List name and Address of any agency, government or private, to whom you have reported this matter:

6.Please Describe your complaint in Detail, Including the alleged criminal violation and any evidence available which supports the allegations. Also include Dates, Insurance Policy Numbers, or Claim Numbers if known and names and addresses of witnesses and any other persons who could provide information about this complaint.

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7.If you believe you have supporting documents such as pictures that might assist us in reviewing your complaint, you may submit copies of these via our file upload below, or send them to us by U.S. Mail along with a print out copy of this filled out complaint form. Please do NOT send us your originals of your documents. Our mailing address: Oklahoma Attorney General / attn: Workers Comp / 313 NE 21st ST / Oklahoma City, OK 73105




You may wish to PRINT the completed complaint form for your records before you submit.