Claim Submission Forms Print
PLEASE USE THESE CLAIMS FORMS:

Please remember to save the Microsoft Word™ file before you attempt to send it. Otherwise, we will not get your information. In the event of a fire loss or serious injury, please call our claims team at (877) 782-3291 immediately.

Document Title Format
 DOC
 PDF
Commercial Automobile (includes 1st & 3rd party)   Word Format  PDF Format
General Liability Word Format PDF Format
Commercial Property (includes Inland Marine)   Word Format  PDF Format
     
First Report if Injury or Illness (FL)   Word Format  PDF Format
Employer's First Report of Injury or Illness (TX)    Word Format  PDF Format
Employer's Report of Occupational Injury or Illness (CA)    Word Format  PDF Format
     
Workers' Compensation - First Report of Injury or Illness (AR)   Word Format  PDF Format
Employer's First Report of Injury or Occupational Disease (GA)   Word Format  PDF Format
Employer's First Report of Injury (IL)   Word Format  PDF Format
Workers’ Compensation - First Report of Injury or Illness (LA)    Word Format  PDF Format
Employer's Basic Report of Injury (MI)    Word Format  PDF Format
Employer's Report of Industrial Injury or Occupational Disease (NV) Word Format PDF Format
Workers' Compensation - First Report of Injury or Illness (SC) Word Format PDF Format
Employer's Accident Report (VA) Word Format PDF Format
 


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