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Non-compliant Employer Referral Form

Use this form to report an employer suspected of failing to maintain workers’ compensation insurance coverage for employees. This form is only for reporting failure to maintain insurance coverage. Report suspected insurance fraud directly to the Kentucky Department of Insurance at 502-564-1461.

The required information in the referral form must be completed to initiate an investigation. If the required information is insufficient or incomplete, the referral will not be assigned for investigation. Prior to submitting a referral use the "Insurance Coverage Lookup" link on our home page to verify an employer’s coverage status.

Please enter the requested information below. Provide as much information as possible. An asterisk (*) notes the required fields.

An asterisk (*) denotes required fields

* Name of business: * Error - Name of business is required

* Owner's Name: * Error - Owner name is required

* Address: * Error - Address is required

* City: * Error - City is required

* State: * Error - State is required

* County: * Error - County is required

Is this a residential address:

Yes

Business phone number:

Number of employees:

What type of work is performed at this business?

Has there been a recent work related injury at this business?

Yes

If an injury occurred and assistance is needed in filling out an injury claim, call the Department of Workers' Claims Specialists Division at 1-800-554-8601

If yes, what is the date of injury?

Job site address/location/directions:

What is the estimated remaining time for this employer to complete work at this job site?

Less than 24 hours

More than 24 hours

Other relevant information:

Contact Information (Optional) We will use this to contact you to clarify or obtain additional information regarding this referral.

First Name:

Last Name:

Phone Number:

Email Address: