How to File a Claim-ORIGNAL
The Pennsylvania Bureau of Workers’ Compensation ONLY accepts electronic injury reports from Insurers and requires submission of an injury report within 48 hours for injuries resulting in death and within 7 days for all other injuries. If you have not submitted your claim already, please do so immediately.
For Lackawanna Insurance Group to timely report injuries to the Pennsylvania Bureau of Workers' Compensation the insured must immediately after an injury complete and submit our First Report of Injury Form. It is necessary to complete at least the required fields on our First Report of Injury Form since this information is required by the Pennsylvania Bureau of Workers’ Compensation.
In addition, please fax or mail their signed Workers' Compensation Information, Employee Notification and Authorization forms from the Claims Kit.
If you do not have your original Claims Kit, you may download a full Claims Kit here: Claims Kit
Important Notice
If you have a panel list of physicians that includes the appointment scheduling services by Premier Comp Solutions please be advised that scheduling an appointment is not the same as reporting the injury. You must submit a First Report of Injury form to Lackawanna Insurance Group.
Methods for Filing a Claim
We provide three (3) methods to submit our First Report of Injury form, and they are listed in order of preference:
Online Claim Reporting
Need to report a claim? . . . No problem!
Just use our quick and easy Online First Report of Injury Form and you are finished in just minutes.
You will receive a confirmation that your on-line First Report of Injury was successful
Fax:
If you cannot complete the form online, you may also download and complete the First Report of Injury form our Report a Claim form and submit via fax.
DOWNLOAD FORM: First Report of Injury form (PDF)
FAX TO: Lackawanna Insurance Group @ 570-824-7969
Mail:
If you cannot fax the completed form, you may mail the form:
DOWNLOAD FORM: First Report of Injury form (PDF)
MAIL TO:
Lackawanna Insurance Group PO Box 270 Wilkes Barre, PA 18703
