Claims Reporting Form

If you prefer to download a PDF version of this form please download, complete, scan, and email to

If the injury is NOT a medical emergency:

  1. Upon notification of an occurrence, an Accident Loss Notice should be completed. Do not delay in reporting the claim, even if you don’t have all the information. You will be notified of any additional information needed.
  2. The injured employee should complete the Employee Statement.
  3. The HIPAA release should be signed.

Claims Reporting Packet
  • Incident Report
  • Employee Statement
  • Supervisor Statement
  • Witness Statement
  • HIPAA Authorization
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Incident Report

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Time of Accident

I certify that the above information is true and correct to the best of my knowledge. I understand that if I am declining medical treatment at this time that my Employer will not be responsible for any expense related to the Incident or any resulting injury. I further understand that I will not be eligible for benefits under the plan unless I receive medical care from an approved provider within 14 days from the date of incident.