Web Reported Claim

Begin Your Claim

Name of Person Reporting Claim

*First Name

*Last Name

Address

*Work Phone

Extension

Cell Phone

Are you a party to the claim?

Yes No

Policyholder

Insurer/Carrier Name

Address

Carrier FEIN

Policy or Self Insured#

Insured Name

Self Insured?

Yes No

Insured FEIN

Policy Effective Date

Policy Expiration Date

Employer

*Company Name

Physical Address

*Work Phone

Extension

Cell Phone

Mailing Address (Leave empty if same as Physical Address)

Employer FEIN

Employer SIC/NAICS Code

Location Code #

Division #

Employer Contact First Name

Employer Contact Last Name

Work Phone

Extension

Cell Phone

Employer Nature of Business

Medical Providers

Medical Provider #1

Medical Provider Name

Address

Phone

Medical Provider #2

Medical Provider Name

Address

Phone

Medical Provider #3

Medical Provider Name

Address

Phone

Hospital Name

Address

Phone

Witnesses

Witness #1

Address

Contact Phone

Cell Phone

Witness #2

Address

Contact Phone

Cell Phone

Witness #3

Address

Contact Phone

Cell Phone

Summary

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Attachments

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Workers Compensation Claim

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Employer