Worker Wage and Employment Information

Note: Please send any Supervisor or witness statements and/or Report of Accident you have on file to [email protected]
Fields marked with * are required

Claim Information

Comments / Concerns

Employment Information

Employment Information

Wage Information

If your employee has hours or wages that vary, including if they work overtime or are paid by piece or job, please send payroll records to [email protected]. We request 12 months payroll prior the date of injury. Or as much as you have, if they have worked less than 12 months.
Note: kept on salary (wage replacement benefits) excludes: vacation pay, sick leave, holiday pay, paid time off, or similar types of compensation

Health Care Benefit Information

Return To Work Information

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