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Report a Claim

Workers' Compensation Claim Reporting Tips

Please collect the following information. Do not, however, delay reporting your claim if all the information is not available.

  • Information about the policy and the insured
    • Employer's name
    • Address where the accident occurred
    • Employer's mailing address
    • Description of loss
    • Employer's federal identification number (FEIN)
    • Date the employer was first notified of accident
    • Nature of the employer's business
    • Employer's specific products (if applicable)
  • Information about the injured employee/claimant
    • Employee's ID/social security number
    • Employee's name
    • Employee's address
    • Employee's date of birth
    • Employee's home telephone number
    • Employee's job title
    • Employee's hire date
    • Hours/days of the employee's regular work schedule
    • Full-time or part-time
    • Employee's rate of pay
    • Employee's gross wages per week
  • Information about the accident
    • Date of the accident
    • Time of the accident
    • Did the employee die?
    • Was the employee unable to work at least one full day after the accident?
    • Date the employee last worked
    • Probable length of disability
    • Has the employee returned to work?
    • Date the employee returned to work
    • Description of the injury
    • Description of the accident
    • Location of the accident (street address)
    • Department and work process involved in the accident
    • Names and addresses of any witnesses
    • Did the injured employee see a doctor?
    • Name, telephone number and address of doctor
    • Did the injured employee go to a hospital?
    • Name, telephone number and address of hospital
    • Length of initial hospitalization
    • Injury Form completed by/or an individual reporting this loss?
    • Preparer's title