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Please do not use this form to report Workers Compensation/Longshore claims. These must be reported directly to the carrier concerned, in accordance with the instructions faxed to you at the time of binding or the carriers claims kit.
For all other claims, please fully complete this form and click submit or print it out and fax it to us.
You will receive an acknowledgment of this report
within 2 working days. If you do not receive an acknowledgment, please call or fax us.
Please be as specific as possible when describing the
claim.
If you have additional documentation, please fax it to
our Claims Department at 727-578-9977.
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