Start a Worker’s Compensation Claim
Instructions for successful submission:
- Please complete this form as fully as possible.
- Do not use dollar signs or commas in dollar amount fields. Decimals are okay.
- Example: 9.52 (not $9.52) or 25800 (not 25,800).
- If you are unsure what to enter in a field, or the field does not apply, leave it blank.
- Do not put zeros or “N/A” in date fields.
- If the field is required and does not apply enter “NONE”
If you have any questions, please call our office at 435-652-7520.