Filing a Claim
In case of emergency, medical treatment should be sought immediately at the closest directed care medical clinic or emergency room!
Supervisor to scan and email a copy of the following forms directly to firstname.lastname@example.org or your agent, or to the 7710 Insurance main office address below.
A) To Be Supplied to and Completed by Employee
Workers’ Compensation Injury Notice
As a first report of injury, no longer than 24 hours following an accident – Form B
Authorization to Disclose, Release and Use Protected Heath Information
HIPAA – Form E
B) To Be Completed by Supervisor
(2 documents total)
Supervisor Report of Injury
Employer Report of Industrial Injury
State – Form A. Select your state from the dropdown, download and fill out the form.
C) To Be Completed by Witness
D) Medical Reports
Also attach any medical reports related to the claim
NOTE: Remember to post the “Notice of state Workers’ Compensation Law” in areas accessible to ALL employees and to follow your specific state’s Department of Insurance reporting requirements.
Working together with our partner claims administrators, our proactive approach to workers’ compensation claims combines predictive data analytics, clinical review, claims expertise, and adaptive technology to lower costs and guide claims to better outcomes – including returning injured workers to a healthy, productive life at home and at work as soon as possible.
Easy access to an array of managed care tools, resources, information and insight help our partner adjusters (S&C and York) thoroughly understand the medical aspects of each claim and guide injured workers to the right care from the right provider at the right time. Our partner adjusters are also skilled in recognizing the signs of potential fraud and utilizing their special investigative unit resources to verify legitimate claims and to fight fraud when they find it. 7710 Insurance takes a proactive approach, assisting our policyholders by managing exposure and risk through our SHIELD program, in addition to managing each claim closely throughout the process.