You are here

Submitted by Jburke on May 9, 2016
Answer every question fully and report promptly to avoid a penalty. Employer’s Federal ID Number and Employee Social Security Number MUST be Provided.
* Denotes a Required Field

EMPLOYER  INFORMATION SECTION

(list principal products or services of concern)

EMPLOYEE INFORMATION SECTION

ACCIDENT INFORMATION

INJURY INFORMATION

INSURANCE INFORMATION

Insurance Company Named on Workers' Compensation Policy

Claim Administrator Information

Employer or Representative