Workers Compensation Claims

In the event of a workplace incident, we are ready to provide your employees with the services and attention they need, including 24/7 access to a nurse to discuss appropriate care and treatment plans.

Posting Notices

Phone

Report Injuries 24/7/365
(833) 908-3324
ID No. 040152

Web

Fill out the contact form below

Reporting Information

Your Name*

Insured Contact Name*

You Are A(n)*

Insured Contact Phone (xxx-xxx-xxxx)*

Policy Number*

Alternate Insured Contact Phone (xxx-xxx-xxxx)*

Agency Name

Insured Contact Email*

Insured Business Name*

Confirm Email*

Accident / Injury Information

Date *

Time

:Minute

Time

Timezone

Date Injury Reported to Employer*

Body Part(s) Injured

Type of Injury*

Physical Address or Location Where the Accident / Injury Occurred*

Description of Accident / Injury*

Injured Employee Information

Employee Name*

Employee Address*

Employee City*

Business Location Employee Works Out Of*

Employee State (Abbrev.)*

Average Hours Worked / Week

Employee Zip

Average Weekly Wage / Hourly Rate

Employee Phone (xxx-xxx-xxxx)

Last Day Paid

Employee Date of Birth*

Has the employee sought medical attention?

Employee Gender

Has the employee returned to work?

Employee Date of Hire*

Date Employee Returned to Work

Job Title (Occupation)*

Job Status

Additional Comments

Upload any relevant documentation you wish to submit
.png, .jpg, .jpeg, .bmp, .pdf and video file types accepted.

For NY

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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

For ME, NH and RI

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

For CA

If you are a California resident, please click on the following link for an important notice regarding the collection of Personal Information. California CCPA Notice

Workers Compensation Claims

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Phone

Web

Email

Digital Reporting from Cell Phone

Temporary Prescription ID Card

Reporta Heridas Laborales

Reporting Information

Accident / Injury Information

Injured Employee Information

For NY

For ME, NH and RI

For CA

Workers Compensation Claims