FAMLI Compliance Tip Form

There are statutes, rules and regulations that govern the Colorado Paid Family and Medical Leave Insurance (FAMLI) Act. If you want to report a business or someone at a business for not complying with the statutes, rules and regulations, please complete the form below so we can evaluate the information and determine what, if any, action is required, including the potential of opening a formal investigation.

Reporting Party

Your First Name:	Your Last Name:
Your Phone Number:	Your Email Address

Employer/Business Information

Employer/Business Name

Business Address

Please put physical address; PO Boxes not accepted.

Business City

Business State

Business Zip Code / Postal Code

Please add the five or nine-digit number for Zip Code or Postal Code.

FEIN:

Federal Employer Identification Number

My FAMLI+ Employer Number:

HR Contact First Name:	HR Contact Last Name:
HR Contact Phone Number:	HR Contact Email Address

Private Plan Name (if applicable):

Private Plan Contact First Name:	Private Plan Contact Last Name:
Private Plan Contact Phone Number:	Private Plan Contact Email Address

Rule Violation

The questions in this section are regarding the individual committing the rule violation.

Individual's First Name:	Individual's Last Name:
Individual's Phone Number:	Individual's Email Address

Describe the suspected FAMLI regulatory violation in detail and how the person/business is not in compliance, giving as much information as possible, including names, dates, witnesses, documents, etc:

Description:

Additional Information or Evidence

If you have additional information or evidence to support this claim, please attach it to this form, or send it to cdle_famli_compliance@state.co.us

Upload Files Here:

If you have multiple pieces of evidence to upload, please merge them into one file or into a zip archive.

Confirmation

By submitting this information, I certify that the information being provided is true, correct, and complete to the best of my knowledge and belief.

I Confirm