Fraud and Noncompliance Referral Form (WC-258)

 

General guidelines: Employers with five or more employees are required to carry workers’ compensation insurance with the exception of the construction industry, which requires employers with one or more employees to carry workers’ compensation insurance. For more information, please call 800-592-6003 or visit labor.mo.gov/dwc/employers/reporting-responsibilities to read more about employers’ responsibilities and liability for coverage. 

Instructions: Please complete the required fields for the Fraud and Noncompliance Unit to conduct an investigation. 

Missouri Department of Labor
& Industrial Relations
Division of Workers Compensation
PO. Box 1009
Jefferson City, MO
65102-1009
Phone: 573-751-3403
FraudandNoncompliance@labor.mo.gov

Download a PDF version of this form.

 

Employer Information

Type of Business

Description of the Alleged Violation

Contact Information

Please provide your contact information. As our investigation progresses, we may need to contact the person filing the complaint to obtain more details. If you choose to remain anonymous, it will not be possible for us to notify you of the outcome of the investigation.

Please note that all records, reports, tapes, photographs and similar materials or documents submitted to or obtained by the Fraud and Noncompliance Unit used to conduct an investigation for any violation under the workers’ compensation law are confidential pursuant to §287.128.9 RSMo and not subject to chapter 610, RSMo.

After the Unit completes its investigation, any finding of fraud or noncompliance is presented to the Division Director who may refer the matter to the Missouri Attorney General’s Office for prosecution.