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Materials
Request Form

materals request form

Name(Required)

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Example: WSD-1234567 You can find your policy number on your billing statement, policyholder welcome email, or printed Claims Kit.

To what corporate business address should we mail these materials?

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Which materials are you requesting?

Full Kit

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Insert desired quantity of each state kit you need:

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DE Quantity

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GA Quantity

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HI Quantity

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IA Quantity

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ID Quantity

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IN Quantity

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KS Quantity

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KY Quantity

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LA Quantity

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MA Quantity

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MD Quantity

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ME Quantity

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MI Quantity

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MN Quantity

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MO Quantity

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MS Quantity

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NC Quantity

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NE Quantity

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NH Quantity

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NJ Quantity

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NM Quantity

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NV Quantity

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NY Quantity

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OK Quantity

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OR Quantity

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PA Quantity

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RI Quantity

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SC Quantity

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SD Quantity

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TN Quantity

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TX Quantity

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UT Quantity

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VA Quantity

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VT Quantity

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WI Quantity

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WV Quantity

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Policyholder Perks

Policyholder Perks view

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Quick Start Checklist

Quick Start Checklist view

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How to Report a Claim

How to Report a Claim view

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California Employer's First Report

Work Comp Claims - Your Road to Success view

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Facts about Work Comp (English)

California - Facts about Work Comp (English) view

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OSHA Notice

OSHA Notice view

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False Claims Ticket

False Claims Ticket view

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10 Red Flags of Fraud Flyer

10 Red Flags of Fraud Flyer view

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California MPN Information

CA Premier Medical Provider Network

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CA MPN Medical Authorization Form

Medical Authorization Form view

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CA First Aid Information

CA First Aid Information view

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Fraud Alert Posters (English and Spanish)

Fraud Alert Posters (English and Spanish) view

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Prescription Information

Prescription Information view

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Take a BITE out of Fraud Poster

Take a BITE Out of Fraud Poster view

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Please request labor law posters and OSHA-related materials from your state's labor department.

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Fax: 858.350.2616

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Company

About
Our Story
Philanthropy
Media Center
Suppliers
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About
Our Story
Philanthropy
Media Center
Suppliers
Careers
Contact

Insurance Products

Workers’ Compensation Insurance
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Assumed Reinsurance

Workers’ Compensation Insurance
Catastrophe Insurance
Assumed Reinsurance

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Webinars
Document Center
Fraud Prevention
Injured Workers Center
Nurse Triage Hotline
Telemedicine
Safety OnDemand^®
Risk Management
Surety Services
Explorer Auto Claims

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