Report an
Employers Liability
Claim

Tell us what happened

Please submit your claim using the form below. By completing this form you agree to our privacy policy.

View privacy policy

Report an Employers Liability Claim

"*" indicates required fields

1. Your information

First name*

Last name*

Relationship to claimant*

Employer (optional)

Phone number*

Email*

2. Policy information

Policy number (optional)

Name of insured*

Insured address line 1*

Insured address line 2 (optional)

City*

State*

Zip Code*

3. Address where loss occurred

Address line 1*

Address line 2 (optional)

City*

State*

Zip code*

4. Claim description

Date of loss*

Time of loss*

Describe what happened and how it happened*

Describe who was involved and any witnesses*

Describe the nature of the injury*

5. Other insurance

Other Insurance*

I understand that all other applicable insurance carriers should be notified of this claim

CAPTCHA

If you experience difficulties submitting your claim, please contact us at firstnotice@icwgroup.com or 1.877.442.9669 and select option #3.

This field is for validation purposes and should be left unchanged.

For Agents

For Work Comp Policyholders

Insurance Products

Reporting Claims

Claims Requirements

Injured Worker Services

Payments

Billing

Info

Work Comp Services

Catastrophe Resources

Join ICW Group

Resources

Join ICW Group

Resources

Report an
Employers Liability
Claim

Tell us what happened