TDI/FLI Fraud Reporting Form

If you suspect your personal information has been stolen, or you believe someone is fraudulently collecting temporary disability or family leave insurance benefits, let us know right away by completing this form. In order to assist with our investigation, supply all the information that is known to you.

DS-20 (R-06-24)

I would like to report:

Someone fraudulently using my identity to collect benefits.

Someone fraudulently collecting benefits they are not entitled to.

Claimant Information

Thank you for contacting the Division of Temporary Disability and Family Leave Insurance. If you suspect your identity may have been fraudulently used to file for benefits, please fill out the following fields with as much detail as possible.

First name

Middle name

Last name

Suffix

Social Security Number Double click to view SSN.

Phone number

Street address 1

Street address 2

City

State Value is not selected

Zip

Email address

Most recent employer

Explain fraudulent activity.

Please upload any relevant documentation.

Claimant Information

Thank you for contacting the Division of Temporary Disability and Family Leave Insurance. If you suspect someone may be fraudulently collecting TDI or FLI benefits, please fill out the following fields with as much detail as possible.

First name

Middle name

Last name

Suffix

Social Security Number Double click to view SSN.

Phone number

Street address 1

Street address 2

City

State Value is not selected

Zip

Most recent employer

Explain fraudulent activity.

Please upload any relevant documentation.

Would you like to submit this report anonymously?

Yes

No

Your Contact Information

Name

Phone number

Email address

email_hidden

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TDI/FLI Fraud Reporting Form

Claimant Information

Claimant Information

Your Contact Information