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Claim Entry - Workers' Compensation
Claim Entry - Other Lines
Preparer
Insured
Description
Claimant/Employee
Accident Info
Medical
Witness
Submit
Preparer is a/an
Agent
Policy Holder
Other
Type of Claim
General Liability
Property
Other
Unknown
First Name
Last Name
Phone
Email
Policy Number
If known, a Policy Number will speed up claim processing.
Company/Last Name
First Name
Address 1
Address 2
City
State
Zip Code
Contact First Name
Contact Last Name
Contact Phone
Contact Email
Loss/Accident Description
Accident Location Description
Additional Comments
Last Name
Company/Last Name
First Name
First Name
Address 1
Address 2
City
State
Zip Code
Phone
Email
Date of Birth
Job Title
Date of Hire
Social Security #
Gender
Male
Female
Marital Status
# of Dependents
Wage Type
Wages $
Loss/Accident Date
Loss Time
Date Reported
Time Reported
Loss/Accident State
Returned To Work
Yes
No
Date Returned to Work
Supervisor First Name
Supervisor Last Name
County
Date Last Worked
Body Part
Fatal
Yes
No
Date of Death
Initial Treatment Date
Medical Facility / Doctor
Address 1
Address 2
City
State
Zip Code
Phone
First Name
Last Name
Address 1
Address 2
City
State
Zip Code
Phone
Email
Please send any documents associated with this new claim to
newclaims@bldrs.com
Thank you for using our Claim Entry website.
The following you should recieve via email if the Preparer Email was entered correctly.
Fields in
Bold
are required.
Claim Entry - Workers' Compensation Claim Entry - Other Lines