Report a Claim as a Guest

State Forms

Click on a state below, for that state’s first report of injury.



You must have ADOBE Reader 9 installed to view these forms. The free ADOBE Reader can be downloaded from the ADOBE website (

  • To fax: Click the "Print Form" button at the bottom of the form and fax the completed form to (704) 927-2867, Attn: Claims. Please keep a copy for your records.
  • To email: Click the “Email form” button at the bottom of the form. Your email client will open a new email with the form attached. Please include any additional information in the body of the email.
  • Yahoo, Google, or Hotmail users: Please save the form as a PDF and send as an attachment to

If you are unable to report a claim or would like assistance in completing the claim reporting form, please contact us at 1-866-710-0908 or (704) 405-9448.