File a Claim

File your claim in whichever way is easiest for you - online, email, phone or fax.

Online - Simply complete the claim submission form below.

Phone - Call 800.435.1127

Email - Email [email protected] and include as much information as possible in the body of your email.  The below form may serve as a guide for the kind of information we will need from you.  

Fax - Send your claim to 866.275.6320. Be sure to include as much information as possible.

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Policy Details

Name*

Policy Number*

Contact Name*

Contact Phone*

Your Injured Worker

Name*

SSN  

Phone

Date Of Birth

Date Of Hire*

Address1

Address2

City

State ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Zip code

About Your Claim

Number of Worked Hours/Week*

Last Date Paid

Date of Accident or Injury*

Time of Accident or Injury*

Date Accident/Injury Reported to Employer*

Type of Injury*

Body Part Injured

Where did Accident/Injury Occur?*

Description of Accident/Injury*

Medical Treatment

Has Injured Employee Sought Medical Treatment?* Yes No

 

If yes, Name

Address1

Address2

City

State AAAEAKAPALARAZCACOCTDCDEFLGAGUHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPAPRRISCSDTNTXUTVAVIVTWAWIWVWY

Zip code

Phone

Has employee returned to work?* Yes No

Additional Information

Dispute an Audit form has been submitted successfully.

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Are there any circumstances that are suspicious or questionable about the report of this injury? Yes No

Please Describe*

Claim Submitted By*

Phone Number*

Email*

Additional Comments