Employer’s Report of Incident

Employer’s Report of Incident

Step 1 of 5

  • Are you reporting a Catastrophic (CAT) Claim?

    A Catastrophic (CAT) Claim is defined as the injured worker having one or more of the following conditions:
    • 1. Loss of Life
    • 2. Formal Admission into a hospital for treatment. (This does not include emergency room only visits or treatment).
    • 3. Loss of an Eye
    • 4. Amputation - Full or partial amputation of a limb or other external body part. This includes fingertip amputations with or without bone loss; medical amputations resulting from irreparable damage; and amputations of body parts that have since been reattached.
    If you are reporting a CAT claim, call your account manager immediately before completing this form.