Workers’ Compensation Recovery New Loss Form

Insurer Information:

Name of Insurer:

Date of Referral

Claim Number:

Adjuster Responsible for Subrogation:

Address:

Phone Number:

Fax Number:

E-mail:

Adjuster Responsible for Workers' Comp:

Address:

Phone Number:

Fax Number:

E-mail:

New Loss Information:

Date of Loss*

Loss Location:

Brief Description of Loss:*

If available, please send the Employer's First Report of Injury and all investigative materials

Employer/Insured Information:

Company Name:

Phone Number:

Contact Person:

Address:

Injured Worker's Information:

Name:

Phone Number:

Spouse or Contact Person:

Address:

AWW:

Comp. Rate:

Medical Bills Paid to Date $:

Medical Bills Incurred $:

Indemnity Payments Paid to Date $:

Indemnity Payments Incurred $:

Brief Description of Injury Sustained:*

Injured Worker's Attorney's Information:

Name:

Telephone Number:

Address:

Representing the Injured Worker for: