Note: There are twelve sections to this form. Each section is short but ALL TWELVE SECTIONS MUST BE COMPLETED! (Some sections have no required fields)

Section
test
* = required field

1. Company This Claim Is To Be Reported To

* = required field

2. Person Reporting

State
* = required field

3. Policy Holder Information

State
* = required field

4. Policy Holder's Client Information

State
* = required field

5. Loss Location Information (i.e. where the injury occurred)

State
* = required field

6. Injured Employee

State
* = required field

7. Injured Employee Employment Information

* = required field

8. Incident Description

* = required field

9. Medical Provider Information

State
* = required field

10. Witness Information

State
State
State
* = required field

11. Additional Remarks

* = required field

12. Anti-Fraud Statment and Digital Signature

Anti-Fraud Statement

Any person who willfully makes a false statement or representation of a material fact for the purpose of obtaining or denying any benefit or payment, or assisting another to obtain or deny any benefit or payment shall be guilty of a crime and subject to fines and/or imprisonment.

Digital Signature

The Electronic Signatures in Global and National Commerce Act (ESIGN, Pub.L. 106-229, 14 Stat. 464, enacted June 30, 2000, 15 U.S.C. ch.96) provides that electronic signatures and records are just as good as their paper equivalents, and therefore subject to the same legal scrutiny of authenticity that applies to paper documents. To complete a digital signature, simply type your name twice in the following boxes. Note: Date will be recorded electronically as of the date that the form is submitted.

I CERTIFY THAT MY ANSWERS ARE TRUE TO THE BEST OF MY KNOWLEDGE

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