​​​​​ Claims

The right people doing the right thing

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Claim Submission

Person Reporting Claim

First Name *


Last Name *


Phone Number *


Email Address *


Alternate Phone Number


Contact Information

First Name *


Last Name *


Email Address *


Phone Number *


Alternate Phone Number


Insured Information

Policy Number


Insured Name *


Mailing Address *


City *


State *


Zip Code


Type of Claim *


Date and Time of Accident *

Select a date from the calendar.  

Location of Accident


Description of Accident *

Claimant Information

First Name


Last Name


Address


City


State


Zip Code


Phone Number


Birthdate

Select a date from the calendar.  

Last Day Worked

Select a date from the calendar.  

Is claimant still off work?


Describe Injury

Healthcare Information

Name of Provider


Address


City


State


Zip Code


Phone Number


Check if you acknowledge the disclaimer:


Check the box if you acknowledge the Fraud Notice


Attachments
 
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