Workers Compensation Claim

Policy Number

Date of Injury / Illness

Time of Injury / Illness

Date Claim Reported

04/19/2024

Please select:

Individual Business

First Name

Last Name

First Name of Primary Contact

Last Name of Primary Contact

Title / Relationship to Insured

Home / Primary Phone

Work Phone

Cell Phone

Email Address

First Name of Alternate Contact

Last Name of Alternate Contact

Title / Relationship to Insured

Home / Primary Phone

Work Phone

Cell Phone

Email Address

First Name of Employee

Last Name of Employee

Address of Employee

City

State

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip

Home / Primary Phone

Work Phone

Cell Phone

Email Address

Social Security Number

Date of Birth

Date of Hire

State of Hire

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Marital Status

select One Single Married Divorced Separated Unknown

Sex

select One Male Female Unknown

Occupation / Job Title

Type of Injury / Illness

Part of Body Affected

Severity of Injury / Illness

Please make a selection Minor Moderate Severe

Initial Treatment

Please make a selection No Medical Treatment Minor: By Employer Minor Clinic / Hospital Emergency Care Hospitalized > 24 Hours Future Major Medical / Lost Time Anticipated

How injury or illness / abnormal health condition occurred. Describe the sequence of events and include any objects or substances that directly injured the employee or made the employee ill.

Name of Physician / Health Care Provider

Address

City

State

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip

Name of Hospital /
Off Site Treatment Facility

Address

City

State

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip

First Name of Person Reporting Claim

Last Name of Person Reporting Claim

Title / Relationship to Insured

Enter your email address here if you would like to receive an electronic confirmation that this claim has been successfully submitted.