Text Size:
Business Insurance Claim Reporting
State-Specific Questions
A C D G H I K L M N O P R S V

Alabama

  • Employee's county
  • Has employee returned to work (Y/N)?
  • If yes, at what occupation?
  • If yes, at what wage?
  • Employer's ID (U.C. Account) number
  • Specific product(s) the business produces

Arizona

  • Last day of work after injury
  • Number of days per week company usually works
  • Department number
  • If validity of claim is doubted, state reason
  • Has injured been employed for more than 12 months?
  • Was employee on overtime when injured?

Top

California

  • State Unemployment Insurance Account Number (UIAN)
  • Date employee was provided claim form

Colorado

  • Employer Federal ID#
  • Employee's length of experience at this assignment
  • Has employee returned to work (Y/N)?
  • If no, estimated date of return
  • Does employee receive room benefits (Y/N)?
  • Will room benefits continue during disability (Y/N)?

Top

Delaware

  • Employer's UC Reporting Number
  • Employee's county
  • Has employee returned to work (Y/N)?
  • If yes, at same wage (Y/N)?

District of Columbia

  • Employer ID #
  • Has employee returned to work (Y/N)?
  • If yes, at what time?
  • If yes, at what wage?
  • Was injured hired in DC?
  • Was employee in his/her regular occupation when injured?
  • Was injured given Form #7 DCWC?
  • Piece or time worker (Piece, Time or Blank)

Top

Georgia

  • Wage rate at time of injury
  • Do you have a Managed Care Organization (MCO) contract (Y/N)? (if unknown select N)
  • First day employee failed to work a full day
  • Did employee work the next day (Y/N)?
  • Return to work wage
  • Return to work wage is per (I.e. day, week, month)

Top

Hawaii

  • Was employee furnished meals or lodging?

Top

Illinois

  • Has the injured worker signed a medical authorization?
  • If yes, inform them to please fax the signed medical authorization to the med auth customer service specialist at 877.786.5567.

Top

Kansas

  • SIC number
  • Was worker admitted to hospital (Y/N)?
  • If yes, date of admission
  • Emergency room only (Y/N)?
  • Has employee returned to work (Y/N)?
  • If yes, light duty (Y/N)?
  • Is further medical aid needed (Y/N)?
  • Is compensation now being paid (Y/N)?
  • If yes, date of initial payment
  • Fatal (Y/N)?
  • If yes, name and address of dependents

Top

Louisiana

  • Employer's Federal ID number
  • Employer's UI reporting number
  • Has employee returned to work (Y/N)?
  • If yes, at same wage (Y/N)?
  • Last full day paid
  • If occupational disease, date of initial diagnosis
  • Parrish of injury

Top

Maine

  • State Employer Unemployment Insurance Account Number (UIAN)
  • Federal Employer Insurance Number (FEIN)

Massachusetts

  • Federal ID number
  • Has employee returned to work (Y/N)?
  • Did employee return to his/her regular occupation (Y/N)?
  • Describe nature of business or article manufactured: S (Service), W (Wholesale), R (Retail), M (Manufacturing)
  • Date reported as work related

Michigan

  • Federal ID Number

Minnesota

  • Date employer notified of lost time
  • NAICS Code

Top

Nevada

  • How long employed by you in Nevada (years, months)
  • If validity of claim is doubted, state reason

New Hampshire

  • Federal ID number
  • Was the employee injured in his/her regular occupation (Y/N)?
  • Was injured hired in New Hampshire?
  • Time disability began
  • Number of full-time employees
  • Number of part-time employees
  • If leased or temporary worker, client's business name
  • Was accident caused by injured's failure to use or observe safety regulation?
  • Probable length of disability
  • Has employee returned to work (Y/N)?
  • If yes, at what occupation?
  • Returned at full duty (Y/N)?
  • Returned at alternative/light duty (Y/N)?
  • Initial treatment: (Check all those that apply)
    • No medical treatment
    • Care provided by employer only (on site)
    • Emergency care
    • Hospitalized
    • Other
    • Outpatient
    • Clinic
    • Office Visit
    • Other, explain
  • Is there a managed care program (Y/N)?
  • If yes, name provider
  • Is there a written safety program in force (Y/N)?
  • Is there an active safety committee (Y/N)?
  • Employee's legal first name (Please validate)

New York

  • Did you provide medical care?
  • If yes, when?
  • Has employee returned to work (Y/N)?
  • If yes, at what weekly wage?
  • Injured worker's work week
  • Fatal?
  • If yes, name and address of nearest relative
  • Relationship

North Carolina

  • Regular wages per day
  • Average weekly wages with overtime
  • Has employee returned to work (Y/N)?
  • If yes, at what time?
  • If yes, what date?
  • Return to work at what wage?
  • Per (i.e. day, week, month)
  • Return to work at what occupation?

Top

Ohio

  • Time accident reported to employer
  • Has employee ever filed a previous application for this injury?
  • Has employee filed any other claims with the Bureau of Industrial Commission? (if yes, specify claim number and body parts)
  • Employee's county
  • Employer's risk #

Oklahoma

  • Was employment agreement made in Oklahoma?
  • SIC number
  • Type of ownership: (P) Private, (S) State Government, (C) County, Government, (L) Local Government

Oregon

  • Hospitalized overnight as inpatient (Y/N)? (If emergency room only, answer N)
  • Did injury occur during the course of employment?
  • Was accident caused by failure of machinery r product?
  • Did someone (not worker) cause accident?
  • Time worker left work
  • State of hire
  • Is worker premium exempt (preferred worker)?

Top

Pennsylvania

  • Employee's county
  • Bureau code
  • Employer's county
  • NAICS code

Top

Rhode Island

  • Federal ID #
  • Full day lost from work?
  • State Unemployment Insurance Account Number (UIAN)
  • Was this injury previously an incident - only no medical treatment and no lost time (Y/N)?
  • If yes, date employer notified of medical treatment or lost time
  • Category of injury or illness: illness, occupational disease: repetitive trauma: occupational hearing
  • Loss or unknown

Top

South Dakota

  • Federal ID number
  • SIC code number
  • Number of employees
  • Body part injured (2 digits)
  • Cause of injury (2 digits)
  • Nature of injury (2 digits)
  • NAIC code
  • Was employee hired for temporary employment?
  • Carrier code

Top

Vermont

  • Federal ID number
  • Was employee hired in Vermont?
  • Does the employer regularly employ 10 or more employees?
  • Has employee returned to work (Y/N)?
  • If yes, at what weekly wage
  • Was injured paid in full for date disability began (Y/N)?
  • Was employee injured at his/her regular occupation (Y/N)?
  • Fatal?
  • If yes, name, address and relationship of nearest relative
  • Late date paid in full

Virgina

  • Has employee returned to work (Y/N)?
  • If yes, at what wage?
  • Federal Tax ID number

Top

 
Resources
Auto
Reporting a Claim
Telephone Guide
Reporting Form
Property
Reporting a Claim
Telephone Guide
Reporting Form
Liability
Reporting a Claim
Telephone Guide
Reporting Form
Workers Compensation
Reporting a Claim
State-Specific Questions
Telephone Guide
Reporting Form

Report Your Claim

Report your claim
directly - we'll get to
work immediately.

24 / 7 / 365

Business Insurance Claims:

800.238.6225


National Accounts Claims:

800.832.7839


Constitution State Services Claims:

800.243.2490


Construction Claims:

877.828.4132