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Report an Employers Liability Claim

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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

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

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Report an
Employers Liability
Claim

Tell us what happened