Fill and Sign the Work Comp Faqsprocessing Overdue No Response Form

DWC-AU- 906 (Rev. 06/13) AUDIT REFERRAL FORM Claims administrator / Company name Injured worker name Claims administrator’s a ddress Claim number City, state, ZIP Date of injury Date or period of violations Employer SPECIFIC DETAILS OF COMPLAINT Describe the nature of the co mplaint, being as specific as possible. For exa mple, late pay ments of te m porary or per manent disability (the num ber of late payments, if known), failure to pay te m porary or per manent disability, or 10% sel f- i m posed penalties for late pay ments (indicate the periods not paid, if known) , failure to pay or object to m edical treatment or m edical-legal bills, failure to investigate a clai m, unsupported denial of liability for a clai m, et al. Please attach copies of support ing docum entation, if available. Complainant (na me & title) Date Address, city, state, ZIP DIR PRIVACY NOTICE: The Department of Industrial Relations, Division of Workers’ Compensation uses the information in your complaint (1) to monitor workers’ compensation claims administrators; (2) to assist DWC and other government agencies in general civil and criminal law e nforcement; and (3) to conduct research on the workers’ compensation system. If you indicate that you want your complaint kept confidential, the Audit Unit will not share your complaint with any party named in your complaint. If you do not request confide ntiality, the Audit Unit may share your complaint with the claims administrator. Please note that your complaint and your workers’ compensation claim information cannot be disclosed to the public under the Public Records Act. If you have questions about this notice please write to Privacy@dir.ca.gov .