Account/Accident Information

• Caller's phone number and extension
• Caller's title and name
• Reporting state - state where employee is permanently employed
• Subsidiary name and address
• Subsidiary mailing address (if different from above)
• Did the accident occur at the location address? (if no, address where accident occurred)
• Parent company/insured's name
• Location code
• Policy symbol and number
• Nature of business

Employee Information

• Employee's name
• Gender
• Social security number
• Date of birth
• Employee's mailing address
• Employee's home phone number
• Employee's home address (if different from mailing)

Employee Job Information

• Employment status code (FT, PT, seasonal, volunteer, etc.)
• Injured worker type (borrowed, owner, partner, subcontractor, unknown)
• Regular occupation
• Occupation when injured
• Employee's work schedule (regular work hours, hours per day, days per week)
• Employee's wage information (hourly, annual, average weekly, overtime, and additional benefits)
• Date of hire (or length of employment)
• Supervisor's name, phone number and best hours to contact

Accident Information

• Date of injury
• Time of injury
• Date claim reported to employer
• Did employee lose any time from work?
    If yes, is employee back at work? (if yes, date returned)
• Return to work status (light, modified, regular)
• Date employee last worked
• Was injury fatal? (if yes, date of death)
• Accident description
• Do you question the validity of this claim?
• Cause of accident (e.g., slip/fall, lifting, chemical)
• Equipment, material, or substance involved
• Names, addresses and phone numbers of witnesses

Injury Information

• Part of body injured (e.g., head, neck, arm, leg)
• Nature of injury (e.g., fracture, sprain, laceration)
• Prior injury or pre-existing condition(s) (if yes, describe)
• Treatment - note all that apply
  • First aid (treatment and date of 1st treatment)
  • Hospital/Clinic (name, address, phone number, physician name, treatment, date of 1st treatment, length of stay, ambulance used?)
  • Was employee treated in an emergency room?
  • Was employee hospitalized overnight as an inpatient?
  • Physician (name, address, phone number, treatment, date of 1st treatment, specialty)

State-Specific Information

• See Workers Compensation - State-Specific Questions for your individual state.

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Business Insurance Claims:

800.238.6225

National Accounts Claims:

800.832.7839

Constitution State Services Claims:

800.243.2490

Construction Claims:

877.828.4132