Workers Compensation Online Claim Reporting

This kit is provided to new workers’ compensation policyholders and their agents, as well as to all current policyholders when their policies renew. It contains important claims department contact information, instructions, and forms. Use of the forms available on this site are intended for the exclusive use of our policyholders and their agents.

Report Workers Compensation Claims

To report a Workers Compensation claim online, click on the box below.

Note: Enter the Injured worker’s legal name on the injury reports as it appears on their social security card as well as their social security number. This information is required as per Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007.

Report a New Claim

Statement of Wage Forms


The Statement of Wage submission process requires Internet Explorer in order for the SUBMIT button at the bottom of each form to work; Google Chrome will not allow for automatic submission using the SUBMIT button. However, if you choose to use Chrome, you may instead complete the form online and print it to PDF then email it to

Having trouble with the PDF opening in your web browser? Try these solutions from Adobe.

Office Locations

654 Main St.
Rockwood, PA 15557

Toll-Free Phone: 800-837-9062
Phone: 814-926-4661
Fax: 814-926-3249

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