Workers Compensation

Workers Compensation Claim Form


Agent Information Section

Agent Name:
Policy Number:

Employer Information Section

Employer Name:*   
Employer Address:

Please provide at least one of the following

Employer Phone:
Employer Cell Phone:
Employer Email Address:    
Employer's Location Address (if different from one provided above):

Employee / Wage Information Section

Employee Name:*   
Employee Address:
Employee Phone:
Employee Cell Phone:
Employee Email Address:    
Employee DOB: mm/dd/yyyy
Social Security Number:
Date Hired: mm/dd/yyyy
Occupation/Job Title:
Employment Status:
Employee Wage, Hourly:
Employee Wage, Other:
Number of days worked per week:
Full pay day of injury:
Did salary continue:

Occurrence / Treatment Section

Time employee began work:  
Date of Injury/Illness:*     mm/dd/yyyy
Time of Injury/Illness:  
Type Of Injury/Illness:*   
Part of Body Affected:*   
Specific activity the employee was engaged in when the
accident or illness occurred:
Address where injury/illness occurred:
Did injury/illness exposure occur on employer's premises?:
Date Employer Notified: mm/dd/yyyy
Date Disability Began: mm/dd/yyyy
Last Date Worked: mm/dd/yyyy
Initial Treatment:

Hospital Name:
Hospital Address:
Physician/Health Care Provider Name:
Physician/Health Care Provider Address:
Physician/Health Care Provider Phone Number:
Date Return(ed) to Work: mm/dd/yyyy
If Fatal, Give date of death: mm/dd/yyyy
Witness - Name:
Witness - Phone Number:

Reporting Information Section

Your Name:*   
If not reported by our insured, complete the information below
Your Phone Number:
Your relationship to insured:
Additional Comments if Any:
(New Jersey) Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

(Maryland) Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

(Pennsylvania) Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Report a Claim

You may also contact our Claims Department
by phone at 800.498.0954