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REPORT A CLAIM
FORMS
CONTACTS

Report a claim
When an injury occurs, your customer needs to report the claim immediately.

BY PHONE

Simply call 800-234-8242 and advise that you are reporting a claim.
When calling in a claim, please have the following information ready:

  1. Customer's company name and location
  2. Injured employee’s name, social security number, phone number, job title, and rate of pay
  3. An explanation of what caused the accident, the nature of the employee’s injury, and the specific medical provider from the medical network with whom the injured employee will be treated.

BY FAX OR EMAIL

Complete a First Report of Injury Form.
Return to:

REPORT A CLAIM
FORMS
QUESTIONAIRES
ARKANSAS
SOUTH CAROLINA
TENNESSEE
TEXAS
CONTACTS

Forms

Questionaires

Aircraft
Cable-Wire Installation
Concrete Contractor
Convenience Store
Janitorial Service
Landscaping-Lawn Service
Masonry Contractor
Metal Building Erection
Quarry & Pit Operation
Roofing
Sheet Metal Work
Sign Erection
Tow Truck
Trucking


Arkansas

EMPLOYER

First Report of Injury or Illness (FORM-1)


South Carolina

EMPLOYER

First Report of Injury or Illness (FORM-12A)


Tennessee

EMPLOYER

First Report of Injury or Illness (DWC FORM-C20)


Texas

EMPLOYER

First Report of Injury or Illness (DWC FORM-001)
Employer’s Wage Statement (DWC FORM-003)
Supplemental Report of Injury (DWC FORM-6)
Compensation Procedures (Chapter 120)

EMPLOYEE

Employee’s Claim for Compensation (DWC FORM-041)
Employee’s Claim for Compensation - Spanish (DWC FORM-041)
REPORT A CLAIM
FORMS
CONTACTS

Contacts

GENERAL
800.597.1690
contactus@salusworkerscomp.com

BILLING
512.421.2644
billing@salusworkerscomp.com

CLAIMS
512.421.2659
claims@salusworkerscomp.com

LOSS CONTROL
615.486.3379
losscontrol@salusworkerscomp.com

POLICY SERVICES
615.486.3379
policy@salusworkerscomp.com


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