Workers Compensation Claim Report Were you involved in a work related incident that resulted in an injury and/or illness? If so, please provide the following information and one of our staff members will be in touch with you as soon as possible to discuss next steps. Please enable JavaScript in your browser to complete this form.Full Name *FirstLastLast 4 of SSN *Date of Birth *Email *Phone Number *Date of Incident *Where are you working? * Description of what happened *SUBMIT