Loss Report





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Four Easy Steps

Dear Customer:

For on-line workers'compensation claims filing, please use the link to the left.

Note: The most efficient way to report your claim is to call HelpPoint at (800) 435-7764 and speak to caring, well-trained professionals who are standing by right now to begin processing your claim immediately. If you prefer to file your claim online, you may do so in four easy steps. After completing the online form, you will be provided with a reference number, and a helpful representative will call you shortly to continue processing your claim.

For the Hearing Impaired, please call our TTY number: 1-888-891-1660.

Para reportar reclamos en Espaņol llame a 1-877-RECLAMO (1-877-732-5266).

(The boxes with a are required. After completing the required boxes, press the Submit button to register your claim.)
Personal Information
 First name:           
 Last name:           
  Email Address:     
  Policy Number:       -
 I am submitting a claim as a:   
 Street/Apt#:      
 City & State:      
 Zip Code             -
Contact Information
AreaCode-Prefix-Phone-Ext
 Primary Phone#:       --
 Alternate Phone#:    --  Type:
  Best Time to Call:
Call me as soon as possible:  OR   (from) 
  (to)    

 Time Zone      From Day 
                                                     To Day     
Select your preferred language: 
Loss Information
 Incident Date:
 Incident Time:
 Time Zone:    
 Location where loss occurred:    
 Description of what occurred:

       
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