Workers' Compensation Claim Report

What to do in the event of Injury

Call for medical assistance if necessary
Report the claim to our agency or your Insurance Company as soon as possible - if you contact the Insurance Company, please let us know so that we may monitor the claim.

Personal Information

First Name *

Last Name *

Street *

City *

State *

ZIP / Postal Code *

Primary Phone Number *

E-Mail Address *

Date of Injury/Occurrence *

Injured Employee Name *

Employee Date of Birth

Injured Employee Address

Injured Employee Ph. Number

Describe incident *

Place of Incident *

Body Part(s) affected *

Medical Provider Name and Address

Did the employee miss work as a result of Inj. *

Has Employee Returned to Work

Submission Validation

Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

Insurance Websites Designed and Hosted by Insurance Website Builder

Quick Links

Home Our Products Customer Service Payment/Claim Options Report a Claim

About Us Refer A Friend Our Carriers Blog Contact Us

Location

744 Spirit of St Louis Blvd
Suite H
Chesterfield, MO 63005
Phone: 636.519.0059
E: service@hebbeln-ins.com