Workers’ Comp Claim Please enable JavaScript in your browser to complete this form.Employer Name *Employee Manager Name *FirstLastEmployee Name *FirstLastDate of Birth *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *Gender *Please SelectFemaleMaleAre you reporting an Injury or Occupational Disease? *Please SelectInjuryOccupational DiseaseDate and Time of InjuryDateTimeFirst Day of Work MissedDate injury was reported to EmployerWhat state did the injury occur?List any witnesses to the injuryPlease list both first and last nameDescribe cause of injury and how it is work relatedList body parts affected by injuryWhat date was the employee last exposed?When did you first know occupational disease was work related?Form completed by *FirstLastSubmit94379 COMPANY About Us Careers NAVIGATION Services Resources Client Info Employee Info Contact Us CONTACT Office: 469-470-1077 Fax: 214-975-2331 4100 Spring Valley Road Suite 654 Dallas, TX 75035
