NEED A WORKERS COMP FIRST REPORT
OF INJURY?
Click on one of the links
below to download forms.
For other states contact
Donna Bartlett.

If you have a claim and are having difficulty contacting your carrier, please contact us.

CLAIMS CENTER
24 N. 6th St.
Terre Haute, IN
ph. 812.232.0441
fax 812.232.0926

If you prefer, report your claim to our office by choosing from one of the menus below.

Claims

How to Submit a Claim

1) If there is an injury involved, make sure that first aid or emergency treatment is rendered immediately.

2) DO NOT ADMIT FAULT.

3) Report the claim as soon as possible, including the following information:

A) Date and location of accident/incident.

B)
If police or sheriff’s department was contacted, provide the name of the agency and report
     number, if available.

C) List the name of the “contact person” for the insured and for any other parties involved.

D)
Describe what happened, listing location of the incident, any persons involved and/or
    witnesses to the incident. If it is an auto accident, list the year, make and model of your
    vehicle as well as any other vehicles involved.

E)
If there are other persons involved in the incident, provide their names, addresses and phone
    numbers if at all possible. If it is an auto accident, provide the name and policy number of
    their insurance carrier.

F)
If it is a work comp claim, be sure to include the employee’s date of birth and
    social security number.

4) The claim can be submitted directly to the insurance carrier by phone if the insured has his/her
    number – this should be provided in the paperwork delivered by the producer at the time the
    policy was written or renewed.

5)
The claim form provided on our web site can be completed and e-mailed to this office to be
    processed and forwarded to the carrier for handling.

6)
Any insured who has questions about the procedures or who is not comfortable with the procedures
    can call our claims office and the information will be taken by phone and forwarded to the appropriate
    claims office for handling.