Division of Workers' Compensation
Non-Compliance Referral Form
To report an employer that you suspect is violating the workers’
compensation coverage requirements, please complete the form below.
All the required information in the referral must be completed.
This required information will allow the investigator to initiate an
investigation. If the required information is not completed, the
referral will not be assigned for investigation. To make a
referral by phone, please call 1-800-742-2214.
The web referral form is currently under reconstruction.
Please use our new referral form
and either email (the Word form) or mail (the PDF form) to