Report a Claim

*Indicates Required Field
Preparer's Information:
*Preparer's Name
*Preparer's Phone Number
*Preparer's Title
*Date Prepared
*Preparer's email
General Information:
*Policy Number
*Benefit State
*Accident Date
*Accident Time
Employer Information:
*Name
*Federal Employer Identification(FEIN)
*Mailing Address
*City
*State
*Zip Code
*Phone Number
 Nature of Business
*Contact Person
*Contact Phone Number
 Are your Workers Compensation panels posted? Yes No
Employee Information:
*First Name
*Last Name
*Mailing Address
*City
*County
*State
*Zip Code
*Phone Number
*Social Security #
 Age
 Gender Male Female
 Birth Date
 If employee is under age 18,
 please enter certificate #
 Marital Status Single
Married
Divorced
Widowed
*Occupation
*Department
 Hire Date
 State of Hire
 Date in Current Job
 Length in Current Job
*Date Injury Reported to Employeer
 Employee Status Full Time
Part Time
Volunteer
Seasonal Other
 Is the Employee Owner/Officer, Partner? Yes No
 Was employee paid for the day of injury? Yes No
 Days Worked/Week
 Hours Worked/Day
 Hours Worked/Week
 Wages/Hour
 Wages/Day
 Average Gross Wage/Week
 Salary/Month
*Has Employee Returned to Work? Yes No
 If Yes, Indicate Date & Time
 Return Wage
 Paid While Injured? Yes No
 Total Dependents
Accident Information:
 Accident Location (address/department)
 Accident County
 Accident Description
 List All Equipment Employee Was Using at
 Time of Accident
 Work Process Employee Engaged In at
 Time of Accident
 Were Safeguards Provided? Yes No
 Were Safeguards Used? Yes No
 Was Accident on Premises? Yes No
 Time Shift Begins
 (Indicate AM/PM)
 Time Reported
 (Indicate AM/PM)
 Supervisor
 Date Last Worked
 Is this a Lost Time Claim? Yes No
 If Yes, Date Disability Began
 Fatal? Yes No
 If Yes, Date of Death
 If Yes, Name and Address of Nearest Relative
 Did Employee Commit an Unsafe Act? Yes No
 Nature of Injury/Body Part
 Object/Substance Involved
 Reason to doubt validity of claim Yes No
Witness Information:
 Witness Name
 Mailing Address
 City
 State
 Zip Code
 Phone Number
Medical Provider Information:
 Is This Claim For Reporting Purposes Only? Yes No
 Provider Name
 Mailing Address
 City
 State
 Zip Code
 Phone Number
 Was Employee Treated In An Emergency Room? Yes No
 Was Employee Hospitalized Overnight? Yes No
Agent Information:
 Name
Comments: