Oklahoma Office of the Attorney General Mike Hunter

Oklahoma Office of the

Attorney General

Mike Hunter

Workers' Comp, Insurance and Social Security Fraud Complaint Form
* Indicates Required Field
Please provide the Attorney General's Office with your contact information:
First name:
*Middle Name:
*Last Name:
*Please list your street address, city, state and zip code:
*Home phone: (no dashes e.g. 5554443333)
*Work phone: (no dashes e.g. 5554443333)
*E-mail address:
Please provide the following information about the business or individual againt whom you are filing a complaint.
*Business name or last name of the individual:
*Individuals first name:
*Please list the address, including city, state and zip code:
*Phone number: (no dashes e.g. 5554443333)
*Social Security Number, if applicable: (no dashes e.g. 444552222)
*Date of birth: (Format: mm/dd/yyyy)
*If an individual, please state the name, address and phone number of his or her employer:
*Is there a case pending with the Workers' Compensation Court (if applicable)? Yes No
If so, please list the case number:
*Please list the name and address of any agency, government or private, to whom you have reported this matter:
*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.
If you believe you have supporting documents, such as pictures, that might assist us in reviewing your complaint, you may submit copies of these below. You may also send copies of such supporting documents, along with a print copy of this completed complaint form, via U.S. Mail to: Oklahoma Attorney General, attention: Workers' Comp, 313 NE 21st St, Oklahoma City, OK 73105.

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Workers' Comp, Insurance and Social Security Fraud Complaint Form