Claim Forms By State

Select Your State

For your convenience, we have provided links below to state web sites containing workers compensation forms that employers and employees commonly use in connection with a workers compensation claim. Each state website will provide detailed information on employer and employee responsibilities when a claim occurs.

If you have any questions in relation to reporting your claim, or would like to report a claim by phone, please contact our customer service department at 1-800-825-9489. To report your claim by fax, complete your state first report of injury form and fax it to us at (855) 603-8409 within 72 hours of the injury.

* Currently we do not service this state.

Customer Service Contact:

Toll Free: (800) 825-9489
Fax: (855) 603-8409
[email protected]

Customer Service Contact:

Toll Free: (800) 825-9489
Fax: (855) 603-8409
[email protected]