Claim Forms by 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.