Workers’ Compensation Claim

Workers' Compensation :: First Report Form

When an employee is injured while working...

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

Employee Name *

Employee Address

Country

City

State

Zip code

Employee Phone *

Employee Email *

Employer Contact

Person to contact for the insured person

Name *

Phone *

Email *

Incident Information

Date of Incident *

Time of Incident *

Location of Incident

Country

City

State

Zip code

Description of incident *

Form Verification (this proves you're not a robot!)

Please enter any two digits with no spaces (Example: 12) *