Dental 360 Auto Embezzlement 370 Other Medical 310 Suspect Driver 30 Carrier / Licensed Insurer 01 Victim Driver 31 Private Sector Self-Insured 02 Life Suspect Passenger 32 Public Sector Self-Insured 03 Suspect Pedestrian 33 Questionable Death 400 Third Party Administrator 04 Body Shop 08 Suspicious/False Policy Application 420 State Fund (SCIF) 05 Repair Shop / Mechanic 34 Other Life 410 District Office 06 Attorney’s Capper 21 Law Enforcement Agency 07 Workers’ Compensation Incoming CDI Hotline Call 08 Workers’ Compensation Claimant 500 (CDI Use Only) Autobody-Premium 40 Employer Defrauding Employee 510 Other CDI Information Source 09 Contractor 41 Legal Provider 520 (CDI Use Only) Employee Leasing 42 Medical Provider 530 Other Reporting Party 10 Janitorial 43 Pharmacy 540 Manufacturing 44 Misclassification 561 Other Services 45 Under-Reported Wages 562 Professional Employment Agency 46 X-Mod Evasion 563 General Professionals 47 Embezzlement 570 Insured 00 Restaurant/Bar 48 Uninsured Employer 580 Claimant 01 Retail 49 Other Compensation 550 Workers’ Witness 02 Temp. Agency 51 Alias/Also Known As (AKA) 04 Transportation 54 Continued in next column QUESTIONS? Call the Fraud Division Regional Office in your county---- Alpine, Amador, Butte, Calaveras Colusa, El Dorado, Glenn, Lassen, Modoc, Mono, Nevada, Placer, Plumas, (916) 854-5700 Sacramento, San Joaquin, Shasta, Sierra, Siskiyou, Stanislaus, Sutter, Tehama, Trinity, Tuolumne, Yolo, Yuba , Contra Costa, Del Norte, Humboldt, Lake, Marin, Mendocino, , , Solano, (707) 751-2000 , , , , (408) 201-8800 , Inyo, Kern, Kings, , Mariposa, , , (559) 440-5900 Southern Los Angeles and the City of Metropolitan Area County (323) 278-5000 Northern Los Angeles including the San Fernando Valley, , (661) 253-7400 (714) 712-7600 , (909) 919-2200 Imperial, (858) 693-7100
Dental 360 Embezzlement 370 Other Medical 310 Life Questionable Death 400 Suspicious/False Policy Application 420 Other Life 410 Workers’ Compensation Claimant 500 Employer Defrauding Employee 510 Legal Provider 520 Medical Provider 530 Pharmacy 540 Misclassification 561 Under-Reported Wages 562 X-Mod Evasion 563 Embezzlement 570 Uninsured Employer 580 Other Workers’ Compensation 550 Carrier / Licensed Insurer 01 Private Sector Self-Insured 02 Public Sector Self-Insured 03 Third Party Administrator 04 State Fund (SCIF) 05 District Attorney’s Office 06 Law Enforcement Agency 07 Incoming CDI Hotline Call 08 (CDI Use Only) Other CDI Information Source 09 (CDI Use Only) Other Reporting Party 10 General Insured 00 Claimant 01 Witness 02 Alias/Also Known As (AKA) 04 Continued in next column Auto Suspect Driver 30 Victim Driver 31 Suspect Passenger 32 Suspect Pedestrian 33 Body Shop 08 Repair Shop / Mechanic 34 Capper 21 Workers’ Compensation Autobody-Premium 40 Contractor 41 Employee Leasing 42 Janitorial 43 Manufacturing 44 Other Services 45 Professional Employment Agency 46 Professionals 47 Restaurant/Bar 48 Retail 49 Temp. Agency 51 Transportation 54 QUESTIONS? Call the Fraud Division Regional Office in your county---- Alpine, Amador, Butte, Calaveras Colusa, El Dorado, Glenn, Lassen, Modoc, Mono, Nevada, Placer, Plumas, Sacramento, San Joaquin, Shasta, Sierra, Siskiyou, Stanislaus, Sutter, Tehama, Trinity, Tuolumne, Yolo, Yuba (916) 854-5700 , Contra Costa, Del Norte, Humboldt, Lake, Marin, Mendocino, , , Solano, (707) 751-2000 , , , , (408) 201-8800 , Inyo, Kern, Kings, , Mariposa, , , (559) 440-5900 Southern Los Angeles and the City of Metropolitan Area County (323) 278-5000 Northern Los Angeles including the San Fernando Valley, , (661) 253-7400 (714) 712-7600 , (909) 919-2200 Imperial, (858) 693-7100
FD-1-Instructions_Revised-08-20-2018.docx