Information Needed to File a claim:

Policyholder Information:

- Active policy number *
- Mailing address and contact information *
- E-mail Address *
- Nature of Business *

Injured Worker/Employee/Claimant Information:
- Name and Social Security Number *
- Personal information, such as date of birth and gender *
- Contact information, such as mailing address * and telephone number
- Did employee give notice of accident/illness, If so, to whom? *
- Injured employee’s supervisor’s name

Employment information:
- Date of hire
- Wage information
– The injured employee’s gross avg weekly wage *
- Job title *
- Employee’s usual days worked *
- Time employee starts work
- Date stopped working (the last day the injured employee was at work and ceased work activities because of this injury/illness)
- Last day paid (The last calendar day the employee earned wages.)
- How long employer will pay the employee? (Will the employer pay the employee for any lost time due to the injury/illness?)
- Return-to-work information, date and rate employee returned to work

Accident/Illness and Injury Information:
- Date of the accident/illness or injury *
- What was employee doing at the time of injury? *
- How did the accident occur? *
- Where did the accident/illness happen? *
- Nature of the injury, such as laceration or fracture *
- Body part(s) injured *
- Cause of injury *
- Any witnesses? If so, who?
- Names, addresses, contact information for medical providers and/or hospitals from whom the injured worker received treatment
- If employee received medical care, on what date? *

*Required field