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.

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