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)

Supervisor's Incident Form

Medical Authorization Form

Wage Statement Form

Mileage Reimbursement Form

Rx First Fill Card

Please access our Claims Kit during a telephonic WC101

Quick Links

Who is Eligible?

How to Apply

IPEP Reporting Procedures