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
    City
    State
    Zip Code
    Phone
  •  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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