Online Claim Form
INSURED CONTACT PERSON
PROVIDER PANEL INFORMATION
Does the insured have a Provider Panel posted?
Click here to receive a new or updated provider panel.
INJURED WORKER INFORMATION
Date of Birth
Date of Injury
Is the injured worker currently working?
Did the Injured Worker seek medical treatment?
KeyScripts temporary pharmacy cards should be provided to employees at the time of injury. The injured worker can take the card with them to the pharmacy and it is to be used for work related accidents only.
Click here to get a copy of a temporary card for your injured employee and follow the instructions on the card.