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Report A Claim

Claim Assignment

Fill out the form below and click submit. You will receive a claim acknowledgement when the claim is set up and assigned to an adjuster.

Submit a Claim for Workers Comp

Choose One of Four ways to submit a claim

1. Click Here to submit a claim via your own email program.

2. If you have a completed Loss Form, you can send it to our Fax Line: 713-680-2371.

3. If you have a completed Loss Form ready to submit, you may upload it here and send it without filling out the rest of the form.

Upload claim assignment or any additional attachments:

4. Or you can just fill out the form below

*Required Fields

Submit By Company

Customer Number:

*First Name:

*Last Name:

Company Name:

Address:

City:

State:

Zip Code:

Contact Phone Number:

Contact Fax Number:

*Contact Email:

Loss Info

Date of Accident:

Cusomter Claim #:

Location of Accident:

Description of Loss:

Employer Info

Employer / Insured:

Date Accident Reported:

Employer Contact First Name:

Employer Contact Last Name:

Employer Address:

City:

State:

Zip Code:

Employer Work Phone:

Claimant Information

Claimant First Name:

Claimant Last Name:

Claimant Address:

City:

State:

Zip Code:

Claimant Home Phone:

Claimant Work Phone:

Male / Female:

SSN:

Date of Birth:

Occupation:

Investigation Type:

Special Instructions:

If you have any additional attachments please attach them in section two at the top of this form.

Claims Management System

CID:

User:

Pass: