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.

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