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To report injuries by phone, you may call our 24-hour Hotline at 800-762-7811.
*Required Fields |
| Policy Number* | Carrier number*
| Client number*
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| Person Reporting Accident* | First Name*
| Last Name*
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| Business Phone Number* |
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| Would you like an email confirmation for this claim?* |
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| If yes, please enter email address*
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| Date of Accident* |
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| Business Name* | Business Name*
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Business address
where injured
employee works* | Address*
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| City*
| State*
| ZIP*
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| Is the above address where the accident occurred?* |
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| Location of accident* | Address*
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| City*
| State*
| ZIP*
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| Injured Worker (IW) Name* | First Name*
| Middle Name
| Last Name*
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| IW Social Security Number* |
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| IW Home Address* | Address*
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| City*
| State*
| ZIP*
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| Time of Injury* |
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| IW Phone Number* |
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| IW Occupation* |
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| IW Date of Birth* |
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| Male or Female* |
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| Marital Status* |
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| Description of Injury* | (What was the employee doing and how were they injured?) *
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| Agree with Description?* |
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| Nature of injury* |
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| Part of body injured* |
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| Cause of injury* |
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| IW Date of Hire* |
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| IW last day of work* |
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| Did IW return to work* |
| If yes, please enter date*
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Date injury was
reported to Employer* |
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Was IW paid for
date of accident?* |
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| Employee Status* |
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| Rate of Pay* |
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Number of hours
worked per day* |
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Number of hours
worked per week* |
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Number of Days
worked per week* |
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Physician/Hospital
Name (if known) |
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Physician Address
(if known) | Street:
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| City:
| State:
| ZIP:
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Physician/Hospital
Phone (if known) |
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Physician Authorized
by Employer?* |
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| Comments |
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