Worker's Compensation

Board of Indiana





















This form is to be used to report employers for not carrying a Worker's Comp Insurance policy. If you feel that you
are being denied benefits by your employer for other reasons, please contact a case coordinator. Contact information
can be found here.

Your Name:
Your E-mail:
* Employer Name:
* Employer Address:
* Employer Zip:
* Complaint:



Please note that your name and e-mail address are optional elements. If provided, we will keep you apprised
of the progress of our investigation.