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Claim Entry - Workers' Compensation
Claim Entry - Other Lines
Preparer
Insured
Description
Claimant/Employee
Accident Info
Medical
Witness
Attachments
Submit
Preparer is a/an
Agent
Policy Holder
Other
Type of Claim
General Liability
Property
Other
Unknown
First Name
Last Name
Phone
Email
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
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
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 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
First Name
Last Name
Address 1
Address 2
City
State
Zip Code
Phone
Email
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Thank you for using our Claim Entry website.
Please review the claim information under each tab prior to clicking Submit, and click Submit only once.
Once the claim is submitted you should receive a copy via email, sent to the address provided under the Preparer tab. If you do not receive an email, this means we did not receive the claim. Please call 800-883-9305.
If any documents associated with this claim are not included on the previous tab, please send them to
newclaims@bldrs.com
Claim was not submitted due to some failure. Please try submitting again.
You should receive an email if the Preparer Email was entered correctly.
If any documents associated with this claim are not included on the previous tab, please send them to
newclaims@bldrs.com
Fields in
Bold
are required.
