External TIP Form - SIU PROD 2021-06-16



Submission of the document, and the document itself, may qualify as privileged and confidential under State law, including, but not limited to, California Insurance Code section 1877.4. You should consult with an attorney before discussing the submission of this document, or the document itself, whether verbally or in writing, to anyone outside of State Compensation Insurance Fund. You should consult with an attorney if you are asked to provide information about the submission of this document, or the document itself, pursuant to a subpoena or subpoena duces tecum.  

Upon submission of this document, State Compensation Insurance Fund reserves the right to use the document, and the contents therein, in any lawful manner pursuant to State and Federal law. Such usage may include, but is not limited to: 1) dissemination of this document, and its contents, to authorized government agencies as defined under California Insurance Code section 1877.1(a) pursuant to a written request under California Insurance Code 1877.3, and 2) dissemination of this document, and its contents, to an insurance institution, agent, insurance-support organization, or self-insurer pursuant to California Insurance Code section 791.13c(2).

Privacy Notice:  
Except as stated in the Tip Report Privacy Notice, our information collection and handling processes are subject to the Terms of Use and Privacy Policy of this website.  

Tip Report Privacy Notice: Tips are crucial in fighting workers’ compensation insurance fraud, and we appreciate receiving this information from you. You are free to remain anonymous, but if you choose to provide your name and contact information, we will be able to remain in contact with you. If you do choose to provide your name, please note the following:  

By entering information on this form and submitting it to us, including your own personal information, you agree that we may use this information for fraud investigation purposes. If you provide your contact information, we will be able to contact you, if necessary, for additional information to support the investigation. You acknowledge that the information you submit may be provided to law enforcement, when required by law, and you may be identified as the source of this information if these records are subpoenaed or required by a court in discovery.  

When you complete this form, we collect and store the information you provide, which may include your contact and device information, and your written comments about the reported incident or situation, your dropdown menu selections, and information contained in any files you may choose to attach. We will use reasonable measures to protect the information you submit when it is stored, processed or transmitted, and we will share it only with authorized third parties who likewise commit to protect the information using reasonable measures, or when required by law.