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About Us
Subrogation Areas
Large Loss Property Subrogation
Large Fire Loss
Small Property Losses
Workers’ Compensation
Mass Torts
Product Failures
Catastrophic Events
Wildfires
Resources
Blog
Video Blog
Attorneys
Events
Contact Us
Report a New Loss
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(888) 579-1144
Workers’ Compensation Recovery New Loss Form
Name of Insurer
*
Date of Referral
*
Claim Number
*
Adjuster Responsible for Subrogation
*
Address
Email
Phone Number
Fax Number
Address
Email
Phone Number
Fax Number
New Loss Information:
Date of Loss
*
Loss Location
*
Brief Description of Loss
*
Employer/Insured Information:
Company Name
*
Contact Person
Phone Number
Address
Injured Worker's Information:
Name
*
Spouse or Contact Person
Phone
Address
AWW
Comp. Rate
Medical Bills Paid to Date ($)
Medical Bills Incurred ($)
Indemnity Payments Paid to Date ($)
Indemnity Payments Incurred ($)
Brief Description of Injury Sustained
*
Injured Worker's Attorney's Information:
Name
Phone Number
Address
Representing the Injured Worker for:
Workers' Comp
Third Party
Single Wildfire Claims Form
Multiple Wildfire Claims Form