Report a Claim

In order to submit your claim electronically, please follow the instructions below.

  1. Select the State in which the injury occurred by clicking on the
    map or
    drop-down.
  2. Enter information directly into the First Report Of Injury (FROI) form.
  3. Once you’ve completed the information save the document, either by clicking the Save icon or selecting File on the menu and Save As to name the file as you wish. 
  4. Submit the completed FROI to the email address or fax number shown below.

Please select your state:


or click your state on the map

Claim Reporting Options

Hotline:

(866) 479-1554

E-Mail:

This email address is being protected from spambots. You need JavaScript enabled to view it.

Fax:

(321) 206-4525

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