The California Audit Complaint Form is a document used to report issues related to workers' compensation claims. This form allows individuals to detail specific complaints regarding claims administrators and their handling of claims. For those interested in filing a complaint, please fill out the form by clicking the button below.
The California Audit Complaint Form serves as a vital tool for individuals seeking to report issues related to workers' compensation claims. This form is designed to facilitate the submission of complaints against claims administrators, ensuring that concerns are addressed effectively. Key aspects of the form include options for confidentiality, allowing complainants to choose whether their information should remain private. The Department of Industrial Relations (DIR) uses the information provided to monitor claims administrators, assist in law enforcement, and conduct research on the workers' compensation system. Complainants must provide specific details regarding the nature of their complaint, such as instances of late payments or failures to address medical treatment, which helps the Audit Unit assess the situation accurately. Additionally, the form requires essential information, including the claims administrator's details, the injured worker's name, and the claim number, ensuring that all relevant parties are identified. By gathering this information, the form aims to streamline the complaint process while protecting the rights of injured workers.
AUDIT COMPLAINT FORM
IF YOU WANT THIS COMPLAINT TO BE KEPT CONFIDENTIAL, PLEASE MARK THIS BOX:
DIR PRIVACY NOTICE: The Department of Industrial Relations, Division of Workers’ Compensation uses the information in your complaint (1) to monitor workers’ compensation claims administrators; (2) to assist DWC and other government agencies in general civil and criminal law enforcement; and (3) to conduct research on the workers’ compensation system. If you indicate that you want your complaint kept confidential, the Audit Unit will not share your complaint with any party named in your complaint. If you do not request confidentiality, the Audit Unit may share your complaint with the claims administrator. Please note that your complaint and your workers’ compensation claim information cannot be disclosed to the public under the Public Records Act. If you have questions about this notice please write to Privacy@dir.ca.gov.
Claims administrator / Company name
Claims administrator’s address
Injured worker name
Claim number
City, state, zip (physical location only- do not use P.O. Box) Date of injury
Date or period of violations
Employer
SPECIFIC DETAILS OF COMPLAINT
Describe the nature of the complaint, being as specific as possible. For example, late payments of temporary or permanent disability (the number of late payments, if known), failure to pay temporary or permanent disability, or 10% self- imposed penalties for late payments (indicate the periods not paid, if known), failure to pay or object to medical treatment or medical-legal bills, failure to investigate a claim, unsupported denial of liability for a claim, et al. Please attach copies of supporting documentation, if available.
Complainant (name & title)
Date
Address, city, state, zip code
Email: ______________________
DWC-AU-906 (Rev. 05/21)
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