Submit a claim - CompSource Mutual

Submit your claim

Accidents at the workplace, while unfortunate, are a reality that requires swift and compassionate response. When reporting an injury through our claim intake form, you’re setting the stage for an effective and efficient compensation process. Here are some key points to keep in mind:

Accuracy is Crucial: Ensure that all provided information is as precise and complete as possible. The clarity of details can expedite the compensation process.
Timeliness Matters: Reporting the injury promptly can help in achieving a quicker resolution, benefiting both the employer and the employee.
Support & Guidance: Our team is here to guide you every step of the way. If you have questions or require clarification, don’t hesitate to reach out.

WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete, or misleading information is guilty of a felony.

Claim Information

Step 1 of 3

Untitled

Submitted by(Required)

First Name Last Name

Email(Required)

Phone(Required)

Injured Worker(Required)

First Name Last Name

Sex of injured worker

Male

Female

Phone(Required)

Date of Accident or Last Exposure(Required)

Date of Birth

Full Social Security Number if available or last 5

Injured Workers Address

Street Address Address Line 2 City State ZIP Code

Business Name(Required)

Policy Number

Has the employee returned to work?

Yes

Was there a fatality as a result of the incident?

Yes

Has the injured worker sought treatment?

Yes

Description of how injury occurred and what body part affected (Please be specific)

Where did the injury occur?

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

INDUSTRIES

Submit your claim

Claim Information