Workers Compensation Insurance

Workers Compensation Insurance Information

Workers Compensation Claim Form

DLI Proof of Coverage Permit

Third Party Administrator:

Inservco
PO Box 3899
2 North Second St
Harrisburg, PA 17101
Phone: 1-800-356-0438
Kim Piper – extension 4040

How to report a claim:

  1. 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

  2. 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 ahaverstock@susumc.org.
  3. 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.
  4. 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.

  5. For additional assistance, please direct all questions to the Conference Treasurer/Comptroller, Andra Haverstock - ahaverstock@susumc.org or call 717-766-5275.

Reminder: All Conference and Church locations are mandated to post the Department of Labor and Industry Workers Compensation Posting Notice – LIBC 500 (5/09).