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.
Date of Injury/Occurrence *
Medical Provider Name and Address
Did the employee miss work as a result of Inj. *
Has Employee Returned to Work
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
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