To report injuries by phone, you may call our 24-hour Hotline at 800-762-7811.
*Required Fields

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