Skip to content
File A Workers Compensation Claim
EMPLOYER | INSURED INFORMATION
Who Is Submitting This Claim?
First
Last
Mobile Phone
Is It Ok For The Carrier To Text Regarding Your Claim?
Yes
No
Email
Name Of Business
Insurance Carrier
Erie Insurance
Travelers Insurance
Accident Fund
Nationwide Insurance
State Auto
Other
Policy Information
EMPLOYEE INFORMATION
Employee Name
First
Last
Date of Birth
MM slash DD slash YYYY
Social Security Number
Date Of Hire
MM slash DD slash YYYY
State Of Hire
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Employee Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Employee Phone
Employee Email
Sex
Male
Female
Unknown
Marital Status
Unmarried | Single | Divorced
Married
Seperated
Unknown
Number Of Dependents
Occupation | Job Title
Employment Status
Full Time
Part Time
Not Employed
On Strike
Disabled
Retired
Unknown
Apprenticeship - Full Time
Apprenticeship - Part Time
Volunteer
Seasonal
Piece Worker
NCCI Class Code (If Known)
Wage Rate (Example $X Per Hour)
Average Weekly Wages
Number of Days Worked Per Week
Full Pay For Day Of Injury?
Yes
No
Did Salary Continue?
Yes
No
OCCURRENCE | TREATMENT
Time Employee Began Work
:
Hours
Minutes
AM
PM
AM/PM
Date Of Injury | Illness
MM slash DD slash YYYY
Time Of Occurrence (approx)
:
Hours
Minutes
AM
PM
AM/PM
Last Work Date
MM slash DD slash YYYY
Date Employer Notified
MM slash DD slash YYYY
Date Disability Began (If Applicable)
MM slash DD slash YYYY
The 1st day on which the claimant originally lost time from work due to the injury/disease
Employer Contact
First
Last
Name of the individual at the Employer's Premises to be contacted for additional information
Employer Phone
Type Of Injury
Nature of injury or illness (eg. Lacerations to the forearm)
Part Of Body Affected
Indicate the part of body (eg. right forearm, lower back)
Location Accident | Illness Occurred
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
All Equipment, Material Or Chemicals Employee Was Using When Accident Or Illness Exposure Occurred
Specific Activity The Employee Was Engaged In When The Accident Or Illness Exposure Occurred
Describe the specific activity
Work Process The Employee Was Engaged In When Accident Or Illness Exposure Occurred
What was the employee doing?
***How Injury Or Illness / Abnormal Health Condition Occurred. Describe The Sequence Of Events And Include Any Objects Or Substances That Directly Injured The Employee Or made The Employee Ill***
Date Returned To Work (If Applicable)
MM slash DD slash YYYY
If Fatal, Give Date Of Death
MM slash DD slash YYYY
Were Safeguards Or Safety Equipment Provided?
Yes
No
Were They Used?
Yes
No
Select Who The Injured Party Saw For Treatment
Physician | Healthcare Provider
Hospital or Offsite Treatment
NA
Select All That Apply
Physician | Healthcare Provider Name
Physician | Healthcare Provider Contact Person (If Applicable)
Physician | Healthcare Provider Phone
Hospital | Offsite Treatment Provider Phone
Hospital | Offsite Treatment Facility Name
Hospital | Offsite Treatment Facility Contact Person (If Applicable)
Physician | Healthcare Provider Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Hospital | Offsite Treatment Provider Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Initial Treatment
No Medical Treatment
Minor: By Employer
Minor: Clinic | Hospital
Emergency Care
Overnight Hospitalization
Future Major Medical / Lost Time Anticipated
Upload Any Files
Drop files here or
Select files
Max. file size: 50 MB.
Δ