You MUST report all Workers Compensation claims to your supervisor PRIOR to submitting this form. Failure to do so may result in a denied claim.

Employee New Claim Submission
Will you seek medical attention? *
Nature of Injury
Head Injuries
Upper Body Injuries
Lower Body Injuries
Signed Authorization for Medical Release

Maximum file size: 50MB

Refusal of Medical

Maximum file size: 50MB

Additional Uploads

Maximum file size: 50MB

reCAPTCHA