Claim Forms

Need to fill out a form?  Please click on the form below that you need to submit.  Fill it out on this website, and all your information will be sent to us.

Claim Forms

Employer's Report of Incident

Employer’s Report of Incident

(Employer Must Complete)

Employee's Report of Incident

Employee’s Report of Incident

(Employee must complete, but Employer may transcribe)

Witness Statement

Witness Statement

(If applicable, Witnesses must complete)

Refusal of Dr. Care

Refusal of Doctor’s Care

(If applicable, Employee must complete)

Master Policy Numbers

WC526-00001-023-SZ  – Applicable for Maine

WC053-00001-023  – Applicable for AK, AL, AR, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KY, MD, MI, MO, MS, NC, NE, OK, RI, SC, TN, TX, VA, VT, WV

If you do business in one or more Multiple Coordinated Policy (MCP) states, a unique policy number for each MCP state will be assigned to you.

Need a Printable Form?

Download the forms on this page and fill them out using your PDF reader.

General Forms

Catastrophic Claim 
Reporting Instructions
Incident Investigation Checklist
Employers Report of Incident
Employers Report of Incident (Spanish)
Employee’s Report of Incident
Witness Statement
Refusal of Doctor Care

Light-Duty Templates

Light-Duty Sample Letter 1
Light-Duty Sample Letter 2
Light-Duty Job Offer Sample

Authorization for Medical Treatment & Pharmacy First Fill

There are two versions of the form, with each applicable in certain states. Each form specifies the applicable states in red text at the top of the first page.

Click Here for Version 1 – For injured workers in Maine and New Jersey

Click Here for Version 2 – For injured workers in all other states where we offer coverage.

 

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