Claim - Midwestern-FNOL

Your Information

Your Name*

Job Title

Preferred Contact Method*

Phone

Email

Phone

Ext

Email

*Claim notification will be sent only if email address provided.

Your Relationship to Injured Person

Your claim number is:

What to Expect Next

A confirmation email will be sent to you if you have provided the email address.
A representative will be contacting you by phone or email within the next 24 to 72 hours to collect more information about your claim.
Your claim number has been reserved but additional information is required to process your claim. Help us expedite your claim by providing additional information now using the ‘Provide Additional Information Now’ button below.
A completed First Notice of Loss form will be available to download if additional information is provided.
We’re here to help. If you have questions now and don’t want to wait, call us at 1-800-356-8457.

Injured Claimant

Address

City

State

Zip

Best Contact Phone

Email

SSN(No dashes)

Gender

Marital Status

Number of Dependents

Date of Birth

Date of Death

Incident Location

Did the incident occur at the same location?

Yes

No

Location Name

Address

City

State

Zip

Employer Information

Date Employer Notified

Incident Description:

Employment Location Information

Do you know the employment location?

Yes

No

Additional Incident Details

Supervisor

First Name

Last Name

Title

Phone

Ext

Email

Lost Time

Yes

No

Salary Continued

Yes

No

Receive Full Wage - Day of Injury

Yes

No

Return to Work Date

Last Date Worked

Employment

Job Title

Status

Full-Time/ Part-Time

Hire Date

Termination Date

Wage

Frequency

W2 or 1099 Employee

Injury Info

Body Part

Cause

Nature of Injury

Medical Treatment Sought?

Yes

No

Medical Treatment

Witness Info

First Name	Last Name	Best Contact Phone	Action
No witness have been added

Additional Infomation

Where specifically did the injury occur?

Who at the incident location have you notified of the incident? (example: Name and Position)

Have you notified your employer of the incident?

Yes

No

Were there any safeguards or safety equipment provided?

Yes

No

What time did the employee begin work on the day of the injury?

Additional Notes/Comments

Are there any additional notes or comments you would like added to the report?