Insured Information
Policy Number*  
Company Name  
First Name*  
Last Name*  
Daytime Telephone Number*  
Mobile Telephone Number  
Fax Number  

Your Email Address*


For Insurance Agents & Brokers Only: Brokers Name

Claim Details
Date of injury/illness*  
Time of occurrence*  
Injured Employee name, address, telephone, date of birth, date of hire, and social security number*  
Complete description of injury/illness*  
Date returned to work  
Physician/Hospital name and address  
Name of person completing this form*  
Date of completion*