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Filling Out a Form

Claim Forms

For your convenience, forms needed to file a claim may be downloaded and forwarded to [email protected] upon completion.

First Report of Injury (State Form 34401)

Wage Statement Form

Supervisor's Incident Form

Medical Authorization Form

Mileage Reimbursement Form

Rx First Fill Card

Please access our Claims Kit during a telephonic WC101

Quick Links
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Who is Eligible?
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How to Apply
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IPEP Reporting Procedures
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Toll Free 800.382.8837

Phone 765.457.9161

Fax 765.868.3310

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Email [email protected]

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IPEP is an Indiana not-for-profit corporation organized in December 1989. Its purpose is to operate a self-funded group program for the purpose of satisfying the obligations of the members under the Indiana Workers' Compensation Act, the Indiana Workers' Occupational Diseases Act and the Indiana Employers' Liability Act. Membership in IPEP is limited to political subdivisions and governmental entities of the State of Indiana.

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