Forms
Auto Accident
Work Accident
Employer
Employer 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)*:
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)*:
Your name (if we have additional questions) (realname)*:
Your Policy Number:
Policy effective from:
to
Insurance Claim #:
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:
