Home
About
Solutions
Services
eSubrosa
File A Claim
✕
Workers' Comp Claim
Facebook
This field is for validation purposes and should be left unchanged.
POLICY INFORMATION
EMPLOYER’S NAME
(Required)
IF YOU HAVE ALL THE EMPLOYERS INFORMATION
YES
NO
NAME / DBA
(Required)
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
CONTACT PERSON / SUPERVISOR
(Required)
BUSINESS PHONE NUMBERS
(Required)
FAX NUMBER
EMAIL ADDRESS
EMPLOYEE’S NAME
(Required)
NAME / DBA
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
PHONE NUMBER
(Required)
ALTERNATE CONTACT NUMBER
Email
(Required)
GENDER
MALE
FEMALE
D.O.B.
DRIVER LICENSE NUMBER
(Required)
SSN
(Required)
LEAVE / DISABILITY DATE
(Required)
LAST DATE WORKED
(Required)
HAVE WORKED ANY FULL OR PARTIAL TIME HOURS SINCE YOUR DISABILITY?
YES
NO
STATE DATE
(Required)
END DATE
(Required)
LOSS INFORMATION / LEAVE TYPE
TYPE OF LOSS
Work Related Injury
For My own illness or injury
Pregnancy
Family Leave
To Care for a family member who is ill or injured
Family bonding: Newborn, foster child, stepchild, or adopted child
Other
LOSS DESCRIPTION
(Required)
LEAVE / DISABILITY DATE
(Required)
DATE YOU RECOVERED OR RETURNED TO WORK?
(Required)
STATE DISABILITY CASE NUMBER
STATE
CASE NUMBER
DOCTOR’S INFORMATION
NAME
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
CONTACT PERSON / SUPERVISOR
PHONE NUMBER
ALTERNATE COTACT NUMBER
EMAIL
Δ
