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REPORT A CLAIM
FORMS
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
ARKANSAS
FLORIDA
NORTH CAROLINA
PENNSYLVANIA
SOUTH CAROLINA
TENNESSEE
TEXAS
CONTACTS

Forms

Arkansas

EMPLOYER

First Report of Injury or Illness (FORM-1)


Florida

EMPLOYER

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

EMPLOYEE

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


North Carolina

EMPLOYER

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

EMPLOYEE

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


Pennsylvania

EMPLOYER

First Report of Injury or Illness (LIBC-90)


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
214.446.8236
policy@salusworkerscomp.com


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