Workers Compensation Claim

Locate an Agent

Workers Compensation Claim

General Information
02/03/2023
Insured / Policyholder Information
Primary Contact Information
Alternate Contact Information
Employee Information
Information Regarding Injury / Illness
Information Regarding Medical Care
Additional Information
Enter your email address here if you would like to receive an electronic confirmation that this claim has been successfully submitted.

Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.