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.
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
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
Alabama
Alaska
Contact Midwestern’s Claims Department for Instructions at (502) 429-9990.
Arizona
Arkansas
California
California Claims must be reported through our California Claims office, which does business as MWIA Administrators. Please click the link below to be directed to the MWIA Administrators website.
mwiaadministrators.comColorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Contact Midwestern’s Claims Department for Instructions at (502) 429-9990.
Illinois
Indiana
Kansas
Workers’ Compensation Rights and Responsibilities
Kentucky
Maine
Maryland
Massachusetts
Michigan
Minnesota
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
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.
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Vermont
Washington
Contact Midwestern’s Claims Department for Instructions at (502) 429-9990.
West Virgina
Wyoming
Contact Midwestern’s Claims Department for Instructions at (502) 429-9990.