IPEP Reporting Procedures

Claim Forms

For your convenience, forms needed to file a claim may be downloaded and forwarded to ipepclaims@ipep.com upon completion.

First Report of Injury (State Form 34401)

Supervisor's Incident Form

Medical Authorization Form

Wage Statement Form

Mileage Reimbursement Form

Please access our Claims Kit during a telephonic WC101

Are you eligible for membership?

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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.

Toll Free: 800-382-8837

Phone: 765-457-9161

302 S Reed Rd. P.O. Box 1247

Kokomo, IN 46903-1247

Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

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