Worker's Comp - 1st Report of Injury

Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Step 1	Verify that everyone is safe. Check for injuries, when in doubt, please dial 911.
Step 2	Do not discuss the incident with other parties. Limit your discussion of the incident to the police and your insurance agent. Do not admit fault.
Step 3	Write down contact information for all parties involved. Include names, phone numbers, and insurance information. In addition to contact information write details about the incident.
Step 4	If your phone has a built in camera, take pictures to perserve the scene for later review.
Step 5	Use the following form to notify us of the worker's comp - 1st report of injury.

Important Notice Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us. Per the terms of our online privacy policy we will not resell your information to any third-party.