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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

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Basic Claim Details

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Insured Data

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Client Codes:

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Accident Details

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Claimant

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Workers' Compensation Data

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Local Policy Information

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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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