Workers' Compensation Report a Claim Form

WorldRisk International Claims

Highlighted(*) items represent required fields. Please enter 'N/A' if any piece of information is not available and/or local Privacy Laws prohibit disclosure.

Important Notice: This form does not eliminate the contractual requirement under our policy to forward every demand, notice, and/or summons received by the insured or their representative to the insurer. Nor does it eliminate the insured's obligation to comply with any filings required by any state or government agencies.

Basic Claim Details

Producer Name :

Producer Address:

Producer Telephone:

Producer Email:

Producer Contact:

Local Policy No.:

Effective Date:

Expiration Date:

Issuing Office:

Master Policy Number:

Master Policy Issuing Office:

Accident Date:

Accident Time:

Previously Reported:

Reported By:

Reference No.:

Insured Data

Insured Name:

Insured Address:

Insured Business Phone No.:

Insured Email:

Insured Contact:

Client Codes:

Stat Code Field 1:

Stat Code Field 2:

Stat Code Field 3:

Stat Code Field 4:

Accident Details

Accident Location:

Accident Description:

Claimant

Employee Name:

Employee Phone Number:

Employee Email:

Description of Injury :

Workers' Compensation Data

Employee Position/Occupation:

Where is the employee currently located?:

Employee losing time from work?:

As of what date?

Injury Sustained & What Body Part:

Wages Per Week/Day:

No. of Days Worked Per Week:

Regular Days Off:

Attending Physician:

Physician Phone No.:

Supervisor:

Supervisor Phone No.:

Name of Witness:

Witness Phone No.:

Witness Email:

COMMENTS

Local Policy Information

WC/EL Limit:

Country of Residence/Citizenship:

Submit Claims To:

^{* Choose United States Dallas no Local Policy}

Official Government & State reporting forms need to be completed & filed as required under the law. Copies should be forwarded to the appropriate claim office. Please click here for all official U.S. Department of Labor Reporting Forms - For Longshore & Defense Base Act only. (This link will open a new window so your form remains intact). You will still need to click the "Submit Loss" button to process this claim form.

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Private Client Group

Workers’ Compensation (AIG Go WC)

Report a Claim

Dental, Group Life, and AD&D Claims

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myAIG Portal for North America

Report a Claim

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U.S. Producer Appointment and Licensing

Report a Claim

IntelliRisk Advanced

AIG Multinational Insurance Fundamentals

myAIG Client Portal for Multinational

Private Client Group

Workers’ Compensation (AIG Go WC)

Report a Claim

Dental, Group Life, and AD&D Claims

IntelliRisk Advanced

myAIG Portal for Multinational

AIG Multinational Insurance Fundamentals

myAIG Portal for North America

Report a Claim

IntelliRisk Advanced

myAIG Portal for Multinational

AIG Multinational Insurance Fundamentals

U.S. Producer Appointment and Licensing

Report a Claim

IntelliRisk Advanced

AIG Multinational Insurance Fundamentals

myAIG Portal for Multinational

Workers' Compensation Report a Claim Form

WorldRisk International Claims

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Workers’ Compensation (AIG Go WC) 

Workers’ Compensation (AIG Go WC) 