Claims Form

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 *
    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 *
    Phone *
    Social Security # *
    Age *
    Gender *
    Birth Date *
    Marital Status
    Job Title *
    Hire Date
    State of Hire *
    Date Injury Reported to Employer *
    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
    Paid While Injured No: Yes:
    Total Dependants
  • Step 4 of 6
    *Required Field

    Accident Information

    Accident Location *
    Accident Description *
    Injury/Disease (ID)
    Date Reported to Employer
    Supervisor
    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

    First Name
    Last Name
    Address
    Address2
    City
    State
    Zip
    Phone
NeboWeb Design CMS Tracking