(Employer Must Complete)
(Employee must complete, but Employer may transcribe)
(If applicable, Witnesses must complete)
(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, 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.
Incident Investigation Checklist
Employers Report of Incident
Employers Report of Incident (Spanish)
Employee’s Report of Incident
Refusal of Doctor Care
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.
The Adobe Reader is required to view and print the PDF files found on this page and throughout our site. If you don’t have this program installed on your computer, download it for free by clicking on the icon below.