Claim Forms

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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

Business Insurers of Georgia SUNZ – WC014-00001-021

InSource United Wisconsin Insurance Company (UWIC) – WC526-00001-021-SZ

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.

Business Insurers of Georgia SUNZ

BIOGA SUNZ Authorization for Medical Treatment & Pharmacy First Fill

Need a fillable version of the form above? Click Here

InSource United Wisconsin Insurance Company (UWIC)

InSource UWIC Authorization for Medical Treatment & Pharmacy First Fill

Need a fillable version of the form above? Click Here


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