Workers' Compensation Claim Report


What to do in the event of Injury

  • Call for medical assistance if necessary

  • Report the claim to our agency or your Insurance Company as soon as possible - if you contact the Insurance Company, please let us know so that we may monitor the claim. 

 



Personal Information
First Name
Required
Last Name
Required
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
E-Mail Address
Required
Date of Injury/Occurrence
Required
/ /
Injured Employee Name
Required
Employee Date of Birth
Optional
Injured Employee Address
Optional
Injured Employee Ph. Number
Optional
Describe incident
Required
Place of Incident
Required
Body Part(s) affected
Required
Medical Provider Name and Address
Optional
Did the employee miss work as a result of Inj.
Required
Has Employee Returned to Work
Optional
Submission Validation
Required
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.