CLAIMS TOOLS | Report a Claim | Claims Tips | Preventing Fraud | Claims Downloads

FIRST REPORT OF INJURY FORMS

 ARKANSAS First Report of Injury/Illness Form (PDF)
 LOUISIANA First Report of Injury/Illness Form (PDF)
 MISSISSIPPI First Report of Injury/Illness Form (PDF)
 OKLAHOMA First Report of Injury/Illness Form (PDF)
 TEXAS First Report of Injury/Illness Form (PDF)

Your claim can be reported by phone, fax or mail. Upon receipt of your claim, we will file the appropriate documents with the proper regulatory authorities in your state.

 Claims Reporting Guide (Adobe PDF)

WAGE STATEMENTS

 ARKANSAS Wage Statement (PDF)
 LOUISIANA Request for Wage Info - Unit Worker (PDF)
 LOUISIANA Request for Wage Info - 4 Week Period (PDF)
 MISSISSIPPI Wage Statement (PDF)
 OKLAHOMA Wage Statement (PDF)
 TEXAS Wage Statement (PDF)

MEDICAL AUTHORIZATION

 Authorization for Release of Medical Records (PDF)

SECOND INJURY FUND QUESTIONNAIRE FOR LOUISIANA EMPLOYERS

 Second Injury Fund Questionnaire (PDF)
 Second Injury Fund Questionnaire (Word)
 Second Injury Fund Questionnaire (in Spanish)

FRAUD GUIDE FOR EMPLOYERS

 Fraud Guide for Louisiana Employers (PDF)
 Fraud Poster for Louisiana Employers (PDF)

REPORTING FRAUD

If you suspect a case of fraud, please click here to contact our claims department or call (800) 311-0997.

In Louisiana, you can report fraud online to the Louisiana Office of Workers' Compensation.
In Texas, you can report fraud online to the Texas Department of Insurance.