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WorldSource International Claims

Highlighted(*) items represent required fields. Please enter 'N/A' if any piece of information is not available and/or local Privacy Laws prohibit disclosure. 

Important Notice:
 This form does not eliminate the contractual requirement under our policy to forward every demand, notice, and/or summons received by the insured or their representative to the insurer. Nor does it eliminate the insured's obligation to comply with any filings required by any state or government agencies.

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Workers Compensation Claim Report Form

 

Basic Claim Details

 
 
 
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Insured Data

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Client Codes:

 
 
 
 

Accident Details

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Claimant

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Workers' Compensation Data

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Local Policy Information

 
 

Official Government & State reporting forms need to be completed & filed as required under the law. Copies should be forwarded to the appropriate claim office. Please click here for all official U.S. Department of Labor Reporting Forms - For Longshore & Defense Base Act only - This link will open a new window so your form remains in tact. You will still need to click the "Submit Loss" button to process this claim form.

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