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

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Contact Information

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Example: john@yourisp.com

Employee Information

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Remarks

04/29/2017






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