Report a claim
When an injury occurs, the claim needs to be reported immediately, even if you do not have all information.
BY EMAIL
Complete a First Report of Injury Form.
Return to:
- EMAIL: newloss@salusworkerscomp.com
BY FAX
Complete a First Report of Injury Form.
Return to:
- FAX: 512-708-9487
BY PHONE
Simply call 888.981.1702 and advise that you are reporting a claim.
When calling in a claim, please have the following information ready:
- Your company name and location
- Injured employee’s name, social security number, phone number, job title, and rate of pay
- 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.
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
Arizona
EMPLOYER
First Report of Injury or Illness
California
EMPLOYER
First Report of Injury or Illness
Colorado
EMPLOYER
First Report of Injury or Illness
Connecticut
EMPLOYER
First Report of Injury or Illness
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)
Idaho
EMPLOYER
First Report of Injury or Illness
Illinois
EMPLOYER
First Report of Injury or Illness
Indiana
EMPLOYER
First Report of Injury or Illness
Iowa
EMPLOYER
First Report of Injury or Illness
Kansas
EMPLOYER
First Report of Injury or Illness
Kentucky
EMPLOYER
First Report of Injury or Illness
Louisiana
EMPLOYER
First Report of Injury or Illness
Maryland
EMPLOYER
First Report of Injury or Illness
Massachusetts
EMPLOYER
First Report of Injury or Illness
Michigan
EMPLOYER
First Report of Injury or Illness
Minnesota
EMPLOYER
First Report of Injury or Illness
Mississippi
EMPLOYER
First Report of Injury or Illness
First Report of Injury or Illness Instructions
Missouri
EMPLOYER
First Report of Injury or Illness
Montana
EMPLOYER
First Report of Injury or Illness
Nebraska
EMPLOYER
First Report of Injury or Illness
Nevada
EMPLOYER
First Report of Injury or Illness
New Jersey
EMPLOYER
First Report of Injury or Illness IA1
New Hampshire
EMPLOYER
First Report of Injury or Illness
New Mexico
EMPLOYER
First Report of Injury or Illness
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
Oregon
EMPLOYER
First Report of Injury or Illness
Pennsylvania
EMPLOYER
First Report of Injury or Illness
Statement of Wages (LIBC-494a)
Rhode Island
EMPLOYER
First Report of Injury or Illness
South Carolina
EMPLOYER
First Report of Injury or Illness (FORM-12A)
South Dakota
EMPLOYER
First Report of Injury or Illness
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)
Utah
EMPLOYER
First Report of Injury or Illness
Vermont
EMPLOYER
First Report of Injury or Illness
Virginia
EMPLOYER
First Report of Injury or Illness
West Virginia
EMPLOYER
First Report of Injury or Illness
Wisconsin
EMPLOYER
Contacts
GENERAL
888.981.1702
contactus@salusworkerscomp.com
BILLING
512.421.2644
billing@salusworkerscomp.com
CLAIMS
888.981.1702
claims@salusworkerscomp.com
LOSS CONTROL
615.571.6465
losscontrol@salusworkerscomp.com
POLICY SERVICES
888.981.1702
policy@salusworkerscomp.com