(Non-Hospitalization Claims Only)
Insured: (required)
Assoc. Member No: (If applicable):
Policy number
Policy period start date
Policy period end date
SIR:
Date of loss:
Accident State: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Claim #:
Claimaint(s):
Date of birth:
Marital Status: SingleMarried
NCCI Job Class Code:
Job Description:
Has a COVID-19 test come back positive? YesNo
This Claim: Has been investigated and found compensable. *Additional information may be requested separately.Has been investigated and is denied.Currently remains under investigation.
Additional Pertinent Information:
Form Completed By:
Date Completed:
Company:
Address:
Phone:
Fax:
Email:
Please attach the Employer’s First Report of Injury and all pertinent file material. (10mb max)
❌
[nocaptcha grecaptcha]
1832 Schuetz RdSt. Louis, MO 63146
888-995-5300
314-995-5300