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Report A Claim


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Contact Information
First Name
Required
Last Name
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Primary Phone Number
Required
E-Mail Address
Required
Employer Information
Employer Name
Required
Street Address
Required
City
Required
State
Required
ZIP / Postal Code
Required
County
Required
Supervisor Name
Required
Supervisor Phone #
Required
Policy #
Optional
Employee Information
Employee Name
Required
Employee's Current Mailing Address
Required
City
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State
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Zip
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County
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Phone #
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Social Security #
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Gender
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Date of Birth
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/ /
Marital Status
Optional
Total Number of Dependents
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Job Title
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Hire Date
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/ /
Employment Status
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Hours and days worked per week
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Regular Days Off
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Is employee owner/officer or partner?
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Did the employee return to work?
Required
If yes, what date did they return to work?
Optional
/ /
Accident Information
Accident Date
Required
/ /
Accident Location Address
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City
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State
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Zip
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Accident Description
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Date Reported to Employer
Required
/ /
# of Employees Injured
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Fatal Injury
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Nature of Injury (Body Part)
Required
Witness Information
Witness Name
Optional
Address
Optional
City
Optional
State
Optional
Zip
Optional
Phone #
Optional
Hospital Information
Hospital Name
Optional
Street Address
Optional
City
Optional
State
Optional
Zip
Optional
Phone
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Additional Comments
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Submission Validation
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.