Type of Request Type of Request: Workers' Compensation Claim Unemployment Claim FMLA Case
Claimant Name: Claimant Name:
Email:: Email:
Phone Number:: Phone Number:
Employer: Employer:
Claim Number (if applicable): Claim Number (if applicable):
Notes regarding your inquiry (i.e. claim status, request a bill, request to speak with Account Executive):: Notes regarding your inquiry (i.e. claim status, request a bill, request to speak with Account Executive):
