Claim Forms By State

Select Your State

For your convenience, we have identified some workers compensation forms that employers and employees commonly use in connection with a workers compensation claim. The link below will direct you to a state-by-state matrix, which lists these forms. If there is a form you need but do not see on the matrix, please contact the office assigned to your claim for further assistance.

Please use the chart below to download a PDF of your claim form by state. If you have any questions in relation to reporting your claim, please contact our customer service department. When the form is complete, fax it back to us at (855) 603-8409 within 72 hours.

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