Workers' Compensation :: First Report Form

Basic information about the claim must be filled out and submitted below as soon as possible.

Employer Contact
Person to contact for the insured person
Incident Information
reCAPTCHA is required.

This website provides a general summary of the insurance coverages that you should consider. It is interpretive only and is not intended to replace or supersede any of the terms and/or conditions of the policies comprising the insurance program. In case of specific interpretation of coverages, you need to refer to the actual policies. Please Note: You cannot contract for coverage by means of e-mail or by requesting information or coverage through this website. Coverage will only become effective after your account has received approval by the insurance company and a deposit premium is received in our office.