Complete As Many Fields As Possible

- indicates required fields

Please complete the requested information below so we can help process your employee's medical claims as quickly as possible. We will use this information to bill your workers' compensation carrier. You are at step1 of the employer worker's compensation form to enable employers to process their employee's medical claims. Please complete the requested information below so we can help process your employee's medical claims as quickly as possible. We will use this information to bill your workers' compensation carrier. The employer worker's compensation form has has five basic steps: 1. patient information, 2. employer insurance information 3. insurance policy information, 4. other Information, and 5. submission Confirmation. You will not be able to proceed to the next step until you fill in all the required fields of the step you are at. You are now at Step 1. You can use tab to enable skip link. If your screen reader announces the following links, the following links correspond to the form steps. If your screen reader does not accounce the following links, you will get to them anyway without issue.

Should you require assistance in completing this form, please contact a ClaimAssist representative at 1.877.831.7204.