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    Report a claim

    State Injury Occurred*:                                
      What is the business name?*
      What is the 3CU policy number?
      If policy number is not available, what is the Federal ID number?
      Briefly describe the nature of the business:
      What is your name (first, last)?*
      What is your title?
      What is your phone number, including area code?*
      What is the injured employee's name?*
      What is the injured employee's social security number?
      What is injured employee's date of birth?
      What is the injured employee's home address? (include state, city and zip code)
      What is injured employee's home phone number, including area code?
      Is the injured employee a male or female?   Male    Female
      What was the date and time of the injury?*
      What is the injured employee's job title or occupation?
      If applicable, what is the department code?
      What is the full address of business location injured employee works? (Include, city, state & zip code)*
      Was the employee injured at the location listed above? Yes    No
      If 'No', provide the full address where the injury did occur?
    (Include city, state & zip code)
      What is the injured employee's date of hire?
      What is the injured employee's hourly rate?                                 
      What time did the injured employee begin work on the day of injury?
      Will the injured employee miss time from work?  Yes   No
    If yes, how many days? 
      Will the employee be paid in full for the day of injury? Yes   No
      What was the last day the injured employee worked due to injury?*
      What date did the injured employee return to work, or is expected to return to work?*
      What date was the injury reported to the employer?
      What type of injury did the employee sustain? For example, contusions, lacerations, or burns.
      What body part(s) was affected?
      How did the accident happen?
      Was the injury fatal?  Yes  No
      If yes, list the date of death:
      Did the injured employee seek medical treatment?   Yes    No
      If yes, what type of medical treatment did the injured employee seek?
      Minor Medical Treatment by Employee
    Hospitalization for more than 24 hours
    Minor Medical Treatment by Clinic/Hospital
    Future major medical/lost time anticipated
    Emergency Care
      Is there any additional information that may be pertinent to this claim?
      To receive an email confirmation of this document, enter your email address here:
      To send an additional email confirmation for this claim to your agent or another recipient, enter the email address here:
      To ensure secure transmission of personal information, a copy of your report will be made available to print after you submit the form, you will also receive a 'confirmation of receipt' email.

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