Workers Compensation Claim
Employer Information
Policy Number:
Employer Name:
Postal Code:
Primary Phone Number: *
Employer Email Address:
Contact First Name: *
Contact Middle Name:
Contact Last Name: *
Contact Suffix:
Contact Phone Number:*
Contact Extension:
Relation to Insured:*

Employee Information
Employee First Name: *
Employee Middle Name:
Employee Last Name: *
Employee Suffix:
Address: *
City: *
State: *
Postal Code: *
Phone Number: *
Occupation/Job Title: *
Date Of Birth: *
Date Hired: *
Social Security Number:

Occurrence/Injury Information
Date of Injury: *
Type of Injury: *

Date Employer was Notified: *
How did the injury occur?: *

Yes No * Did the injury cause loss time from work?
Yes No * Did the injury occur on the Employer's premises?
Select Loss Location:
Location of Loss: *
City: *
State: *
Postal Code:
Yes No * Did the loss result in a fatality?

Additional Loss Information
Yes No * Are you reporting an incident without filing a claim?
Yes No * Was medical attention required as a result of this claim?
Yes No * Were there any witnesses to this accident?
Yes No * Are there any legal documents associated with this claim?
Yes No * Is this loss a result of an Act of Terrorism?
Additional Comments:

Witness Information

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Witness First Name: *
Witness Middle Name:
Witness Last Name: *
Witness Suffix:
Phone Number:

File Attachments
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Reported By Information
Reported By First Name: *
Reported By Middle Name:  
Reported By Last Name: *
Reported By Suffix:
Phone Number:
Date Reported:

Fraud Warning
Any person who, with the intent to defraud or deceive, submits an application or files a statement of claim containing any false, incomplete or misleading information, or helps in any manner to commit a fraud against an insurer, may be subject to civil and criminal prosecution for insurance fraud.
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