Policyholders

Report a claim
Forms
Safety toolbox
Contacts

Report a claim

When an injury occurs, the claim needs to be reported immediately, even if you do not have all information.

BY WEBSITE

Complete a First Report of Injury Form, then upload:

Secure upload





BY EMAIL

Complete a First Report of Injury Form.
Return to:

BY FAX

Complete a First Report of Injury Form.
Return to:

  • FAX: 512-708-9487

BY PHONE

Simply call 800-234-8242 and advise that you are reporting a claim.
When calling in a claim, please have the following information ready:

  1. Your company name and location
  2. Injured employee’s name, social security number, phone number, job title, and rate of pay
  3. An explanation of what caused the accident, the nature of the employee’s injury, and the specific medical provider from the medical network with whom the injured employee will be treated.
Back to top

Forms

Alabama
Arkansas
Delaware
Florida
Georgia
Louisiana
Mississippi
New Jersey
North Carolina
Oklahoma
Pennsylvania
South Carolina
Tennessee
Texas

Alabama

EMPLOYER

First Report of Injury or Illness
First Report of Injury or Illness Codes

Arkansas

EMPLOYER

First Report of Injury or Illness (FORM-1)
Wage Statement

Delaware

EMPLOYER

First Report of Injury or Illness

Florida

EMPLOYER

First Report of Injury or Illness (Interactive)
Wage Statement DWC1A
Brochure for Employers

EMPLOYEE

Brochure for Injured Workers (ENGLISH)
Brochure for Injured Workers (SPANISH)

Georgia

EMPLOYER

First Report of Injury or Illness (WC1)

Louisiana

EMPLOYER

First Report of Injury or Illness

Mississippi

EMPLOYER

First Report of Injury or Illness
First Report of Injury or Illness Instructions

New Jersey

EMPLOYER

First Report of Injury or Illness IA1

North Carolina

EMPLOYER

NC Employer Report of Injury or Illness (FORM-19)

EMPLOYEE

NC Employee Report of Injury or Illness (FORM-18a)
NC Notice of Accident (FORM-18ee)

Oklahoma

EMPLOYER

First Report of Injury or Illness

Pennsylvania

EMPLOYER

First Report of Injury or Illness (LIBC-90)
Statement of Wages (LIBC-494a)

South Carolina

EMPLOYER

First Report of Injury or Illness (FORM-12A)

Tennessee

EMPLOYER

First Report of Injury or Illness (DWC FORM-C20)
Wage Statement (C41)

Texas

EMPLOYER

First Report of Injury or Illness (DWC FORM-001)
Employer’s Wage Statement (DWC FORM-003)
Supplemental Report of Injury (DWC FORM-6)
Compensation Procedures (Chapter 120)

EMPLOYEE

Employee’s Claim for Compensation (DWC FORM-041)
Employee’s Claim for Compensation - Spanish (DWC FORM-041)

Back to top
Back to top