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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.

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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