Claimant fraud:

1. An individual files a claim for an injury that does not exist
   
2. A worker claims an injury occurred on the job when it did not, or takes another job while continuing to seek workers’ compensation benefits
   
3. A claimant makes misstatements to a doctor to obtain medical benefits
   

Employer fraud:

1. An employer misrepresents the nature, size, ownership or experience of his business in order to avoid paying the proper premium
2. An employer understates his payroll or misclassifies his employees
   

Medical fraud:

1. A medical worker orders unnecessary tests and treatments
2. A medical worker charges for services that were never performed
   

Attorney fraud:

1. An attorney recruits clients and manufactures bogus workers’ compensation claims for them
   
   

• The injured worker is a newly hired employee.
• The claimant took unexplained or excessive time off prior to the claimed injury.
• The alleged injury occurred prior to or just after a strike, layoff, plant closure, job termination, completion of seasonal or temporary work or notice of employer relocation.
• The claimant reported the alleged injury immediately following disciplinary action, notice of probation, demotion or being passed over for a promotion.
• The claimant has a history of personal injury, workers’ compensation claims and/or reporting subjective injuries.
• The claimant’s job history shows many jobs held for a fairly short period of time.
• The alleged injury relates to pre-existing injuries or health problems.
• The claimant used addresses of friends, family or post office boxes; the claimant has no permanent known address and moves frequently.
• The claimant’s family members know nothing about the claim.
• The claimant was experiencing financial difficulties and/or domestic problems prior to the submission of the claim.
• The claimant is involved in a high risk activity or hobby, such as skydiving.
• The claimant’s version of the accident has inconsistencies and is not credible.
• There are no witnesses to the accident.
• The witnesses’ versions of the accident conflict with the claimant’s version or with each other’s.
• Facts regarding the accident are related differently in various medical reports, statements and employers’ first injury report.
• The claimant failed to report the injury in a timely manner.
• The accident or type of injury is unusual for the applicant’s line of work.
• The social security number provided does not belong to the claimant.
• The claimant refuses to or cannot produce solid or correct identification.
• The lawyers’ letter of representation or the letter from the medical clinic is the first notice of the claim.
• There is a repeated pattern of doctor or attorney referrals (the same doctor and lawyer work together on a large volume of claims).
• The claimant cannot be reached at home during working hours, despite the fact that he claims to be unable to work; the message taker is vague and noncommittal; the claimant is unavailable and elusive.
• Several of the claimant’s family members are receiving workers’ compensation benefits, unemployment, social security benefits, welfare, etc.
• The claimant refuses diagnostic procedures to confirm injury, or refuses to attend a medical exam scheduled by the defense.
• The claimant’s co-workers express opinions that the injury is not legitimate.
• The alleged injuries are all subjective (soft tissue injuries, pain and emotional issues).
• The claimant frequently changes positions or changes a position after being released to return to work.
• The physician describes the applicant as a muscular, well-tanned individual with callused hands, grease under the fingernails or with other characteristics that are typical of an active worker.
• The medical treatment is inconsistent with the injuries originally alleged by the employee.
• The applicant undergoes excessive treatment for soft tissue injuries.
• A surveillance shows the applicant’s activities are inconsistent with physical limitations related to the medical reports and deposition.
• Surveillances or tips reveal the supposedly disabled claimant is employed elsewhere (this is especially suspicious if the employment conflicts with the general restrictions given by the treating doctor).

• Occupations listed in the claims file do not match the type of business being insured.
  
• There are additions of many DBAs ("doing business as") on a small policy.
  
• The policyholder is claiming "independent contractor" status of employees.
  
• The employees are reporting wages paid in cash or by personal check.
  
• The policyholder appears to be "hiding" injuries by paying medical bills, not reporting, etc.
  
• Employees have difficulty getting claim forms from the employer.
  
• The employer denies all claims.

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