Fields with an * are required to submit a claim  
Name:*
 
 
Address:*
City:* State:* Support table "STATE_CODE_LIT_PO" not found.
Postal Code:*
 
 
Home Phone:*
Business Phone: Extension:
Employee E-mail Address:
 
 
Sex:* Support table "driver_sex_lit" not found.
Marital Status: Support table "WC_MARITAL_ST_LIT" not found.
Date of Birth:*
SSN:*
Occupation/Job Title:*
Date Hired:* Employment Status:* Support table "emp_status_lit" not found.
Average Weekly Wage (last 12 months):

Name:* DBA Name:
 
 
Address:*
City:* State:* Support table "STATE_CODE_LIT_PO" not found.
Postal Code:* Employer E-mail Address:
 
 
Policy Number:
 
 
Business Phone:* Extension:

Date of Injury/Illness:* Time of Injury/Illness:* AM PM
 
 
Injury Description:*

How Did Injury Occur:*
City Where Injury Occurred: State Where Injury Occurred: Support table "STATE_CODE_LIT_PO" not found.
 
 
Did Injury Cause Loss Time From Work:* Yes No
Last Work Date: Date Returned to Work:
 
 
Date Disability Began:
Date Employer Notified: Person Notified:
Injury Occur on Employer's Premises: Yes No
Fatality: Yes No
 
 
Yes No Any Physician and/or Hospital Information Known at This Time?*
 
 
Physician/Health Care Provider:
Address:
City: State: Support table "STATE_CODE_LIT_PO" not found.
Postal Code:
 
 
Hospital Name:
Address:
City: State: Support table "STATE_CODE_LIT_PO" not found.
Postal Code:

 
Yes No   Any Witnesses Known at This Time?*
 
 
Witness Name:    
 
 
Address:
City: State: Support table "STATE_CODE_LIT_PO" not found.
Postal Code:
 
 
Daytime Phone: Extension:
Evening Phone: Extension:

 
Additional Notice of Loss Comments:

Preparer Name:* Preparer Phone:*
Date Prepared:*
Preparer E-mail Address:

Agency Name: Agency Phone Number:

 
 
 Fraud Warning

Any person who, with the intent to defraud or deceive, submits an application or files a statement of claim containing any false, incomplete or misleading information, or helps in any manner to commit a fraud against an insurer, may be subject to civil and criminal prosecution for insurance fraud.