Claim Entry

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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

EXT

Job Title

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

EXT

Contact Email

Job Title

Loss/Accident Description

Max 250 Characters

Address where Accident Occurred

Max 250 Characters

Additional Comments

Max 250 Characters

Last Name Company/Last Name

First Name First Name

Address 1

Address 2

City

State

Zip Code

Phone

EXT

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 to Employer

Date Reported to Insured

Time Reported to Employer

Loss/Accident State

Returned To Work

Yes No

Date Returned to Work

Employer Premises?

Yes No

Supervisor First Name

Supervisor Last Name

County Accident Occurred

Date Last Worked

Injured Body Part

Fatal

Yes No

Date of Death

Initial Treatment Date

Medical Facility / Doctor

Address 1

Address 2

City

State

Zip Code

Phone

EXT

First Name

Last Name

Address 1

Address 2

City

State

Zip Code

Phone

EXT

Please send any documents associated with this new claim to newclaims@bldrs.com

Thank you for using our Claim Entry website.

Please review the claim information under each tab prior to clicking Submit.
Once the claim is submitted, you should receive a copy of this report e-mailed to the address provided under the Preparer information.

The following you should recieve via email if the Preparer Email was entered correctly.

Fields in Bold are required.