Please note - the link to "File a Claim" online which you have saved in your internet brower's bookmarks or favorites is no longer valid.  Please go to the new online form at the link below and replace this in your bookmarks or favorites.  Thank you.

https://online.bldrs.com/claimentry/claims-form.html

REMEMBER — For even faster reporting, you can call toll-free claims reporting at 800.883.9305 — it’s available 24 hours a day, 7 days a week.

  • Step 1 of 6
    *Required Field

    Intro

    Preparer's Name *
    Date Prepared *
    Preparer's E-mail *
    Preparer's Phone Number *
    Policy Number *
    Accident Benefit State *
    Accident Date *
    Accident Time *
  • Step 2 of 6
    *Required Field

    Employer Information

    Company Name*
    Contact Name *
    Address *
    Address2
    City *
    State *
    Zip *
    Phone *
  • Step 3 of 6
    *Required Field

    Employee Information

    First Name*
    Last Name *
    Address *
    Address2
    City *
    State *
    Zip *
    County *
    Phone *
    Social Security # *
    Age *
    Gender *
    Birth Date *
    Marital Status
    Job Title *
    Full/Part Time
    Wage *
    Hire Date
    State of Hire *
    Type of Injury or Injury/Illness Description *
    Is the employee owner/officer, partner?
    Paid Day Injury? * No: Yes:
    Returned to Work? * No: Yes:
    Date Returned to Work
    Time Returned to Work
    Paid While Injured? No: Yes:
    Total Dependants
  • Step 4 of 6
    *Required Field

    Accident Information

    Accident Location *
    Address *
    County *
    Accident Description *
    Injury/Disease (ID)
    Date Reported to Employer *
    Time Injury Reported to Employer *
    Supervisor
    Date Last Worked
    Number of Employees Injured
    Fatal? No: Yes:
    Date of Death
    Nature of Injury/Body Part *
  • Step 5 of 6

    Witness Information

    First Name
    Last Name
    Address
    Address2
    City
    State
    Zip
    Phone
  • Step 6 of 6

    Doctor Information

    Date Visited Doctor
    First Name
    Last Name
    Address
    Address2
    City
    State
    Zip
    Phone
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