Workers Compensation Insurance
Workers Compensation Claim Form
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Claims are handled by our Third Party Administrator:
PO Box 3899
2 North Second St
Harrisburg, PA 17101
Kim Piper – extension 4040
How to report a claim:
- Complete the Workers Compensation Claim Form – Employer’s Report of Occupational Injury or Disease.
Be sure to include all information especially the Employer Federal Identification Number on the form
- Forward completed form and a copy of the latest W-2 or pay stub for the injured employee to the Finance Office – FAX 717-766-7696 or email firstname.lastname@example.org.
- Once your claim has been submitted, you will be provided with a claim number for your medical provider to use in their billing process. You are not required to use any certain providers. You may choose your medical provider.
- If immediate medical attention is needed before your claim number is available, give your provider the Third Party Administrator information listed above and your Social Security Number for claim payments. You must still complete and submit the Workers Compensation Claim Form as described in steps 1 & 2.
- For additional assistance, please direct all questions to Rev. Jason Mackey - email@example.com or call 717-766-5275.
Workers Compensation Insurance Information