Report A Claim

In order to submit your claim electronically, please follow the instructions below.

  1. Select the State in which the injury occurred by clicking on the map below.
  2. Enter information directly into the First Report Of Injury (FROI) form.
  3. Once you’ve completed the information save the document, either by clicking the Save icon or selecting File on the menu and Save As to name the file as you wish. 

Please select your state:


or click your state on the map to the right

Developed in conjunction with Ext-Joom.com

Questions?

Hotline:

(866) 479-1554

Fax:

(321) 206-4525

Developed in conjunction with Ext-Joom.com