File a Claim

File a Claim with Compensation Solutions, Inc.

If you need to file a new claim with us, fill out the form below to get started, and we'll contact you if additional information is needed.

*Denotes Required Field


General Information

*Employer Name
Department
Internal Claim Number
*Injured Employee Name
*Home Address
*City/State/Zip
*Date of Birth
*Gender
*Social Security Number

 Injury Information

Date of Injury
*Description of Accident
*Type of Injury/Disease & Part(s) of Body Affected
Date Reported
Last Date Worked
Return to Work (if known)

 Certification

*Submitted By
*Date Submitted
*Email
Claim Certification
 Certify  Reject
 

Before submitting this form, please click on the link below to move the contents of box "A" into box "B" leaving the first box empty.

A: B: Click to Move