Service provider: fraud and non-compliance referral form

Allegation

Why are you reporting this service provider? *

If other, please specify

Please provide details about your concerns about this service provider * Be as specific as possible.

Please describe any evidence you have to substantiate the allegation

Please attach any images or documents that may be evidence (4Mb Max) Note: files may take a few minutes to upload when you click ‘Next page’.

Document/image

Are you pursuing action through any other process . under the Return to Work Act 2014 to address this concern? * For example an application to the South Australian Employment Tribunal?

Please provide details

Covering South Australian businesses and workers from the cost of work injuries.

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Service provider: fraud and non-compliance referral form