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REPORT A CLAIM
FORMS
SAFETY TOOLBOX
CONTACTS

Report a claim
When an injury occurs, the claim needs to be reported immediately.

BY WEBSITE

Complete a First Report of Injury Form, then upload:

Secure upload





BY EMAIL

Complete a First Report of Injury Form.
Return to:

BY FAX

Complete a First Report of Injury Form.
Return to:

  • FAX: 512-708-9487

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. Your 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.

 

REPORT A CLAIM
FORMS
ALABAMA
ARKANSAS
DELAWARE
FLORIDA
GEORGIA
LOUISIANA
MISSISSIPPI
NEW JERSEY
NORTH CAROLINA
OKLAHOMA
PENNSYLVANIA
SOUTH CAROLINA
TENNESSEE
TEXAS
SAFETY TOOLBOX
CONTACTS

Forms

Alabama

EMPLOYER

First Report of Injury or Illness
First Report of Injury or Illness Codes


Arkansas

EMPLOYER

First Report of Injury or Illness (FORM-1)
Wage Statement


Delaware

EMPLOYER

First Report of Injury or Illness


Florida

EMPLOYER

First Report of Injury or Illness (Interactive)
Wage Statement DWC1A
Brochure for Employers

EMPLOYEE

Brochure for Injured Workers (ENGLISH)
Brochure for Injured Workers (SPANISH)


Georgia

EMPLOYER

First Report of Injury or Illness (WC1)


Louisiana

EMPLOYER

First Report of Injury or Illness


Mississippi

EMPLOYER

First Report of Injury or Illness
First Report of Injury or Illness Instructions


New Jersey

EMPLOYER

First Report of Injury or Illness IA1


North Carolina

EMPLOYER

NC Employer Report of Injury or Illness (FORM-19)

EMPLOYEE

NC Employee Report of Injury or Illness (FORM-18a)
NC Notice of Accident (FORM-18ee)


Oklahoma

EMPLOYER

First Report of Injury or Illness


Pennsylvania

EMPLOYER

First Report of Injury or Illness (LIBC-90)
Statement of Wages (LIBC-494a)


South Carolina

EMPLOYER

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


Tennessee

EMPLOYER

First Report of Injury or Illness (DWC FORM-C20)
Wage Statement (C41)


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
SAFETY TOOLBOX
CONTACTS

Safety Toolbox

JANUARY
Slips, Trips & Falls (PDF)

FEBRUARY
Fire Prevention Plan - Know Where to Go (PDF)

MARCH
Hearing Conservation (PDF)

APRIL
Hand and Portable Powered Tools (PDF)

MAY
Behavior-Based Safety (PDF)

JUNE
Emergency Exits – Designated Path (PDF)

JULY
Heat Stress — Control the Hazards (PDF)

AUGUST
Ergonomics: Reduce Musculoskeletal Disorders (PDF)

SEPTEMBER
Fall Protection(PDF)

OCTOBER
Personal Protective Equipment - Eye and Face Protection (PDF)

NOVEMBER
PPE — Eye Protection (PDF)

DECEMBER
Flammable Liquids - Know the Danger of the Vapors (PDF)

REPORT A CLAIM
FORMS
SAFETY TOOLBOX
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
214.446.8236
policy@salusworkerscomp.com


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