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
Internal Claim Number
*Injured Employee Name
*Home Address
*Date of Birth
*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)


*Submitted By
*Date Submitted
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