The Hanover Insurance Group - Workers Compensation Claim

Report a Workers Compensation Claim Online

Required fields are marked *.

To report your claim online, please complete the form below in its entirety.
When you have finished entering your data, please be sure to press the 'Submit' button to send your information.
After pressing the 'Submit' button, wait for your confirmation message and number before leaving this website.
Please Note: Once your claim has been reviewed, we will contact you directly to obtain additional information.

Employer Information

Policy Number:

Employer Name: *

Address 1: *

Address 2:

City: *

State: *

Zip: *

Supervisor Name:

Supervisor Phone:

Contact Information

Name: *

Primary Phone: *

Secondary Phone:

Email Address:

Example: john@yourisp.com

Employee Information

First Name: *

Middle Name:

Last Name: *

SSN:

- - Example: 999-99-9999

Address 1: *

Address 2:

City: *

State: *

Zip: *

Phone: *

Date of Birth:

Employee State of Hire:

Employee Occupation:*

Date of Hire:

Wages:

Salary:

Hour

Week

Month

Year

Date of Injury: *

Date Reported To Employer:

Address of where
injury occurred:

State where injury occurred: *

Treating Doctor:

Phone:

Address 1:

Address 2:

City:

State:

Zip:

Describe the cause, nature, and extent of the injury: *

Body Part Injured:

Return to Work:

Remarks

Reported by:*

Email Address:*

Who Reported:*

Date Reported:*

03/21/2023

Attachment(s):

After pressing the 'Submit' button, wait for your confirmation message and number before leaving this website.