Worker's Compensation Loss Form (B-3)

Please complete the claim form below, then click Submit to send the claim to Associated Adjusters. Click Clear to clear all fields in order to erase errors or prepare to send another claim.

Employer Name
Employer Address
SIC Code
Employer FEIN
Insured Report Number
Employer's Location Address (if different)
Location #
Phone#
Carrier (Name, Address & Phone#
Policy Period Begin and End Dates
Check if Appropriate Self-Insured
Claims Administrator (Name, Address & Phone#
Policy/Self-Insured Number
Agent Name & Code Number
Employee Name (Last, First, Middle)
Date of Birth
Social Security Number
Employee Address (Include Zip)
Employee Phone#
Sex
Number of Dependents
Marital Status
Date Hired
State of Hire
Occupation/Job Title
Employment Status
Rate $
Per:
# Days Worked per Week
Full Pay for Day of Injury?
Did Salary Continue?
Time Employee Began Work (a.m. or p.m.)
Date of Injury/Illness
Time of Occurrence (a.m. or p.m.)
Last Work Date
Date Employer Notified
Date Disability Began
Contact Name/Phone#
Type of Injury/Illness
Part of Body Affected
Did Injury/Illness Exposure Occur on Employer's Premises? Yes
No
Department or Location Where Accident or Illness Exposure Occurred
All Equipment, Materials, or Chemicals Employee was Using When Accident or Illness Exposure Occurred
Specific Activity the Employee was Engaged in When Accident or Illness Exposure Occurred
Work Process the Employee was Engaged in When Accident or Illness Exposure Occurred
How Injury or Illness/Abnormal Health Condition Occurred. Describe the Sequence of Events and Include Substances That Directly Injured the Employee or Made the Employee Ill
Date Return(ed) to Work
If Fatal, Give Date of Death
Were Safeguards or Safety Equipment Provided? Yes
No
Were They Used? Yes
No
Physician/Healthcare Provider (Name & Address)
Hospital (Name & Address)
Initial Treatment
Witnesses (Name & Phone#)
Date Administrator Notified
Date Prepared
Preparer's Name & Title
Phone Number

 

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