Welcome to our easy, guided online Employee Claim Form.
Attorneys MUST login and use the Claim form with Entry of Appearance.

Here are a few important tips:

• You must enter a valid email address to receive status information
• You must disable pop-up blocker on your web browser
• The green text will help you
• A red “X” message will identify a mistake
• A red asterisk * means required information
• The left column navigation shows your progress and lets you move back and forth
• The claim must be completed in English.

CLICK HERE to get started or look below for more information.

• Add your signature with your mouse, touch screen/touchpad or download, print, sign, scan and upload
• Save your information and submit it later
• Scan/upload only the signed page 2 Medical Authorization. 
  DO NOT scan or upload the personal file copy of the claim form marked DO NOT FILE
• Name your upload file simply, no periods or other symbols
• Use Print a Copy to preview and print a copy of the completed form for your records before you submit the claim.
  You cannot access the claim after it is submitted
• Use the Check Form Status tab to research the status of any claim started in the past 45 days.