ProMedical, LLC
PO Box 310, Bedford, MA 01730-0310
(800) 722-1555 Fax (800) 767-7556

Employer's Form

(701s) This is not a secure form - your responses will be e-mailed to us.

We will use this information to bill your worker's
compensation insurance carrier.

Our file# (ournum) (required)
Date of accident:
Name of employee who was treated for this accident:

Name of Firm:

Firm's mailing address:

Your Workers' Compensation Insurance Carrier information with policy dates including the date of the accident

Your firm's Worker's Compensation Insurance company name:

Insurance Company Address:

Telephone number:
Your e-mail address (if we have additional questions) (email): (required)
Your name (if we have additional questions) (realname): (required)
Your Policy Number:
Policy effective from to (dates)
Insurance Claim # (if available)
Name of adjuster handling this claim:

Has the employee reported this accident to you? YES NO
Have you submitted a report to your insurance company? YES NO

Additional comments:

Press this to , or, press to and clear this form.

Thank you!

Workers' Compensation

Other Forms:

Patient - Auto Accident

Employee - Work Related

We will use this information to bill your worker's compensation insurance carrier.

We will use this information to bill your worker's
compensation insurance carrier.