REPORT A CLAIM
*yellow fields are required
Employee Social Security #:

  Date of Injury:
 Employee First Name:
Employee Last Name:
Street Address:
City:
 State:
 Zip Code:
County:
 Phone Number:
--
 Employee:
 Date of Birth:
Number of Dependants:
Occupation or Job Title:
Occupational Class Code:
 Employment Status:
 Employer:
 Street Address:
City:
 State:
  Zip Code:
Employer Federal ID Number:
 Phone Number:
-
County:
 NAICS Code:
Full pay for day of injury?
 Time of occurence:
Time employee began work:
Last Date Worked:
Date Disability Began:
 Date Employer Notified:
Date Returned to Work (if applicable):
Date of Hire:
Contact First Name:
 Contact Last Name:
Contact Phone Number:
--
Type of Injury:
 Part of Body Affected:
Cause of Injury:
Did injury or illness occur on employer's premises?
 State of Injury:
 Were safeguards or safety equipment provided?
Were safeguards or safety equipment used?
All equipment, materials, or chemicals employee was using when accident
or illness exposure started:
How injury or illness/abnormal health condition occurred. Describe the sequence
of events and include any objects or substances directly responsible:
If fatal, give date of death:
Physician/Health Care Provider

Physician First Name:

Physician Last Name:

Street Address:
 		Initial Treatment:
No Medical Treatment
Minor by Employee
Clinic/Hospital
Panel Physician
Employee Physician
Emergency Care
Hospital (24+ hours)
City:
 State:
 Zip Code:
Hospital

Hospital Name:

Street Address:
City:
 State:
 Zip Code:
Policy Number:
Witness First Name:
 Witness Last Name:
Witness Phone Number:
--
Policy Period From:
Policy Period To:
Person Completing This Form
Name:

Title:

Phone:
( )   		Insurance Carrier
Lackawanna Casualty Co. - FEIN 24-0637535 Bureau Code - 119
Lackawanna American Insurance Co. - FEIN 23-3005758 Bureau Code - 2324
Lackawanna National Insurance Co. - FEIN 51-0525163
 
Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers' Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165.

Step 1 Step 2 Step 3
In order to properly document your records you need to first "Print Form" and then "Acknowledge & Submit". Once you press "Acknowledge & Submit" you cannot go back and print a copy of the completed form.
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