General Instructions for online claim reporting

When submitting a report, please complete the entire Web Loss Report Form and provide all required information. Required fields are marked in bold.

  • The name, contact information, and digital signature for the person reporting MUST be filled in with the correct information.
  • If the mandatory required information is unknown at the time of your web submission, enter “unavailable” in any field requiring text.
  • If the mandatory required information is "not applicable" (such as staffing company if the reporting company is not in a staffing arrangement), enter “NA” in any field requiring text.
  • Enter all 999s in any fields that require a number value. The final report will depend on the accuracy and completeness of the information you are able to provide.
  • No information will be transmitted until you click the “submit” button at the bottom of the form.
  • The Accident Description field has a 200-character limitation. Additional information can be entered in the final remarks area of the submission. Additional Remarks also has a 200-character limitation.

Form Terms

  • Person Reporting: This is you and your information at the company you work for. The contact information is how we can reach you if we have a question. You are most likely work for the staffing company or site client, but you could be the location owner,injured employee, or even someone else making the first report.
  • Staffing Company: This is the staffing company, PEO, etc. that the injured employee is leased from. If your company uses's services, leave this blank. If you were instructed to use this site by a General contractor, then put the GC info here.
  • Site Client: This is the staffing company's client. This is usually a business such as a warehouse, trucking company, etc. This is where the injured employee reports to work or punches their time clock.
  • Loss Location: This is where the accident happened. Example: if the injured employee is a truck driver, he may have been injured at a warehouse across the country. We need to know exactly where the injury occurred. It may not be on your premises.
  • Injured Employee Information: This is all the information about the injured employee. We need this information to report the injury to the insurance carrier so that bills can get paid. We also need to be able to contact the injured employee so that we can ensure that the employee is getting to appointments and back to work as soon as possible.
  • Incident Description: This is the information you received about the injury. If you were only told that the employee was injured, we need complete information to ensure that the claim is work related.
  • Medical Provider Information: If the person received medical from a doctor, hospital, urgent care, etc. This is that information if known.
  • Witness Information: Anyone who witnessed the incident and their contact information.
  • Additional Remarks: Anything else we need to know pertinent to the injury. Do you believe the accident was not work related, did the employee have this injury 2 days ago, did another employee hear this employee say it was not work related, is this your best employee and you believe this is work related, etc.
  • Anti-Fraud Statement: Some states require this on FROI forms, this is also our commitment to preventing fraud for our clients.
  • Digital Signature: This is the legal equivalent to a written signature.
  • Print: Prints the form you just filled in so that you have a hard copy. You need to have a printer connected to your computer to print the form.
  • Submit Loss Information: This button submits the information you just filled in. It will open a new page and clear all the info you just entered.
  • Reset Form: This will clear all the info you just entered in the form.
  • Back: Takes you to the previous web page and clears all the info you just entered in the form.

If you have any questions, please do not hesitate to call us.

If you do not receive a confirmation of claims within 48 hours (2 business days), please contact us.