File a Workers Comp Claim Step 1 of 4 25% Claim Reported By(Required) Email addressEmployer Information | Page 1 of 4NameEmployer's Legal NameFEINAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code nature of BusinessPolicy Number Injured Worker Information | Page 2 of 4Employee NameFull namePhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Worker's ID NumberSSNOccupation at Time of InjuryBirth Date Month Day Year Gender Time and Place of Accident | Page 3 of 4Location Where Accident OccurredDate of Injury Month Day Year Time of Injury Hours : Minutes AM PM AM/PM Date Reported MM slash DD slash YYYY Was the Injury Fatal? Yes No Date of Death Month Day Year Number of Dependent ChildrenMarital Status Single Married Divorced Widowed Nature and Cause of Accident | Page 4 of 4Machine, Tool, or Object Causing InjuryDescribe How Injury or Illness OccurredDescribe Nature of Injury or IllnessIncluding body parts affected If the form does not display, you may be using an unsupported browser (such as Internet Explorer). We suggest updating your browser. Visit this site to update your browser. Need a Different Form? General LiabilityAutoProperty
