Claims Form

  •  Section 1 of 6 

    Required Information

    Preparer's First Name
    Preparer's Last Name
    Preparer's Phone
    Preparer's Email
    Company Name
    Contact First Name
    Contact Last Name
    Contact Phone
    Employee First Name
    Employee Last Name
    Employee Phone
    Returned to Work? Yes  No 
    Date Returned to Work    
    Accident Date/Time



    Accident State
    Date/Time Accident Reported to Employer



    Accident Location Description

    You have 250 characters left of a 250 character maximum.

    Accident Description

    You have 250 characters left of a 250 character maximum.

  •  Section 2 of 6 

    Company / Employer Information

    Policy Number
    Company Address 1
    Company Address 2
    Company City
    Company State
    Company Zip Code
    Company Phone
  •  Section 3 of 6 

    Claimant / Employee Information

    Job Title
    Date of Hire    
    Social Security Number
    Gender Male  Female  
    Marital Status Unknown  Married  Widowed  Separated  Single  
    Date of Birth    
    Number of Dependents
    Wages $
    Wage Type
    Home Address 1
    Home Address 2
    Home City
    Home State
    Home Zip Code
  •  Section 4 of 6 

    Accident Information

    Supervisor's First Name
    Supervisor's Last Name
    Accident County
    Date Last Worked    
    Body Part(s) Injured
    Fatal? Yes  No 
    Date of Death    
  •  Section 5 of 6 

    First Medical Treatment Facility Information

    Medical Facility Name / Doctor
    Initial Treatment Date    
    Address 1
    Address 2
    Zip Code
  •  Section 6 of 6 

    Submit Claim

    Please enter the characters shown in box and click Submit. A confirmation will be sent to the preparer’s e-mail address.



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