We understand that dealing with a new claim can be stressful, and we are here for you. Please report your claim below and we will contact you right away to discuss your options and advise you on the next steps moving forward with your claim.

Or, give us a call at (888) 819-3893

Type of Claim(Required)

Type of Property Loss(Required)

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Other type of Property Loss

Business Name(Required)

Email(Required)

Phone(Required)

Date of Loss(Required)

Location of Loss(Required)

Street Address Address Line 2 City State ZIP Code

Location Description

If street location is unknown, please describe the location of the loss to the best of your ability.

Were the police called?(Required)

Yes

Police Report Number

Description of Loss(Required)

Please describe what happened to the best of your ability.

Upload File(s)(Required)

Upload any additional files such as pictures, police reports, estimates, forms, doctor summaries, etc.

Drop files here or

Max. file size: 12 MB.

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Workers Comp Claim Questions

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Name of Injured Employee(Required)

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Date of Injury(Required)

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Time Employee Began Work

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Date Employee Last Worked

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Date Employer Notified(Required)

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Contact Name

(Optional) Such an union representative, office manager, significant other, etc.

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Contact Phone

(Optional)

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Type of Injury / Illness(Required)

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Part of Body Affected(Required)

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Equipment, Material, or Chemicals employee was using at time of injury / illness(Required)

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What activity was employee engaged in at time of injury / illness

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How did the injury / illness occur?

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Date Employee Returned to Work

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If Fatal, Give Date of Death

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Were Safeguards or Safety Equipment Provided?(Required)

Yes

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Were Safeguards / Safety Equipment Used?(Required)

Yes

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Did Injury / Illness Occur on Employer Premises?(Required)

Yes

Additional Comments or Information(Required)

This field is for validation purposes and should be left unchanged.

Monday	9:00 AM - 5:00 PM
Tuesday	9:00 AM - 5:00 PM
Wednesday	9:00 AM - 5:00 PM
Thursday	9:00 AM - 5:00 PM
Friday	9:00 AM - 5:00 PM
Saturday	Closed
Sunday	Closed

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