Claims

Immediately upon notification of a work-related employee injury, the employer is required to complete a state-specific First Report of Injury Form. Please use the state form that corresponds with the injured employee’s primary state of employment. Links to state forms are provided below.

Upload or mail the completed form to our corporate office at P.O. Box 436909, Louisville, KY 40253-6909 to begin the claims process.  This form may also be faxed to (502) 426-7067. However if faxed, the original copy should also be mailed. If you have questions, contact us at (502) 429-9990.

Although it is  acceptable to provide your insurance agent/agency with a “copy” of the First Report of Injury, please do not rely on your insurance agent to send the First Report of Injury to us on your behalf.


phone(2)When and Whom to Call

Employers must notify Midwestern Insurance Alliance by telephone immediately in the event of a work-related injury that results in the actual or potential loss of life or limb at (502) 429-9990.

You must also report all work-related fatalities directly to OSHA within 8 hours, and must report all work-related inpatient hospitalizations, amputations and losses of an eye directly to OSHA within 24 hours at 1-800-321-OSHA (6742) or by calling the nearest area OSHA office


Use our Online Upload Tool

Upload

The quickest and easiest way to submit a First Report of Injury form is to upload it. Just click the upload logo above to send us documents related to a workers’ compensation claim (to include the First Report of Injury form, supporting documentation, additional forms and photos).

After receiving a First Report of Injury form, a member of our claims staff may contact the injured worker and/or the employer to discuss the claim and to provide information about what to expect during the claims process. Additional information may be needed from the injured employee or the employer as an investigation into the circumstances of the claim will be initiated and medical information gathered to assist in determining if the claim is compensable. [Read more about our claims methodology]

 

State-Specific Forms and Instructions

Alaska

Contact Midwestern’s Claims Department for Instructions at (502) 429-9990.

District of Columbia

Hawaii

Contact Midwestern’s Claims Department for Instructions at (502) 429-9990.

Massachusetts

New Hampshire

North Dakota

Contact Midwestern’s Claims Department for Instructions at (502) 429-9990.

Ohio

Contact Midwestern’s Claims Department for Instructions at (502) 429-9990.

Rhode Island

South Dakota

Tennessee

Forms

First Report of Injury

Required Posting (English)

Required Posting (Spanish)


Initial Choice of Provider Employer must give injured worker panel of 3 physicians not associated in the same practice. If the injury is to the neck or back they must also add a chiropractor to the list, but they are limited to 12 visits. A choice of physicians form must be presented in writing to injured worker and must be signed by injured worker. An appropriate panel must be provided for each attending physician and each operating surgeon.

Change of Provider There is no statutory right for injured worker to change physicians. Employer has the right to have an IME by a physician of its choice at any reasonable time.

Washington

Contact Midwestern’s Claims Department for Instructions at (502) 429-9990.

West Virginia

Wyoming

Contact Midwestern’s Claims Department for Instructions at (502) 429-9990.


injured person in circleThe staff of Midwestern Insurance Alliance and you (the employer) are a team. To perform your role effectively, you should have a modified duty policy in-place, and be familiar with how to detect and deter workers’ compensation fraud.

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