Claims Kit

When it comes to the complexities of workers’ compensation, you can rely on our deep expertise to help you navigate specific state regulations and claims forms. These resources provide the valuable information and tools you need when dealing with a workplace injury.

For help identifying your insurance company, please contact us at 800.231.1363.

Insurance Company*

Resource*

State*

Your Claims Kit will include:

State Forms
Posters & Brochures
State Compliance Information
Injured Worker Resources
Documents Provided by CopperPoint, Alaska National and PacificComp

Arizona

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Colorado

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

New Mexico

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Utah

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Nevada

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Alabama

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Alaska

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Arkansas

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

California

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Connenticut

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Delaware

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Florida

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Georgia

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Hawaii

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Idaho

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Illinois

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Indiana

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Iowa

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Kansas

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Kentucky

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Louisiana

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Maine

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Massachusetts

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Maryland

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Michigan

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Minnesota

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Mississippi

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Missouri

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Montana

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Nebraska

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

New Hampshire

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

New Jersey

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

New York

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

North Carolina

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

North Dakota

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Ohio

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Oklahoma

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Oregon

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Rhode Island

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Pennslyvania

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

South Carolina

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

South Dakota

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Tenneessee

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Texas

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Vermont

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Virginia

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Washington

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

West Virginia

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Wisconsin

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Wyoming

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Washington, D.C.

Claims Kit Contents

Claims Handled By
CopperPoint Insurance Company
3030 North 3rd Street
Phoenix, AZ 85012

Email: ask@copperpoint.com
Phone: 602.631.2300
Phone: 800.231.1363

Alabama

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208.955.8036
Fax: 208.780.7943
boi_claims@alaskanational.com

Arizona

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208.955.8036
Fax: 208.780.7943
boi_claims@alaskanational.com

Arkansas

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208.955.8036
Fax: 208.780.7943
boi_claims@alaskanational.com

Alaska

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208.955.8036
Fax: 208.780.7943
boi_claims@alaskanational.com

California

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208.955.8036
Fax: 208.780.7943
sfo_claims@alaskanational.com

Colorado

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208.955.8036
Fax: 208.780.7943
boi_claims@alaskanational.com

Connecticut

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208.955.8036
Fax: 208.780.7943
boi_claims@alaskanational.com

Delaware

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208.955.8036
Fax: 208.780.7943
boi_claims@alaskanational.com

Florida

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Georgia

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Hawaii

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Idaho

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Illinois

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Indiana

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Iowa

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Kansas

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Kentucky

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Louisiana

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Maine

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Massachusetts

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Maryland

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Michigan

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Minnesota

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Mississippi

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Missouri

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Montana

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Nebraska

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Nevada

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

New Hampshire

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

New Jeresy

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

New Mexico

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

New York

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

North Carolina

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

North Dakota

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Ohio

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Oklahoma

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Oregon

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Pennslyvania

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Rhode Island

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

South Carolina

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

South Dakota

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Tennessee

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Texas

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Utah

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Vermont

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Virginia

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Washington

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

West Virginia

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Wisconsin

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Wyoming

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Washington, D.C.

Claims Kit Contents

Claims Handled By

Alaska National Insurance Company
2501 E State Ave., Suite 100
Meridian, ID 83642
208-955-8036
Fax: (208) 780-7943
boi_claims@alaskanational.com

Arizona

Claims Kit Contents

Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Alabama

Claims Kit Contents

Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Alaska

Claims Kit Contents

Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Arkansas

Claims Kit Contents

Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

California

Claims Kit Contents

Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Colorado

Claims Kit Contents

Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Connecticut

Claims Kit Contents

Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Delaware

Claims Kit Contents

Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Florida

Claims Kit Contents

Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Georgia

Claims Kit Contents

Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Hawaii

Claims Kit Contents

Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Idaho

Claims Kit Contents

Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Illinois

Claims Kit Contents

Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Indiana

Claims Kit Contents

Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Iowa

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Kansas

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Kentucky

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Louisiana

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Maine

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Massachusetts

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Maryland

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Michigan

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Minnesota

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Mississippi

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Missouri

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Montana

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Nebraska

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Nevada

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

New Hampshire

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

New Jersey

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

New Mexico

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

New York

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

North Carolina

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

North Dakota

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Ohio

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Oklahoma

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Oregon

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Pennsylvania

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Rhode Island

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

South Carolina

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

South Dakota

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Tennessee

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Texas

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Utah

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Vermont

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Virginia

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Washington

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

West Virginia

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Wisconsin

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Wyoming

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Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Washington, D.C.

Claims Kit Contents

Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Agreement Between Employer / Employee Choice of Physician

Agreement Between Employer / Employee Choice of Physician (Spanish)

Alternative Choice of Physician or Chiropractor

Application for 104 Weeks Dependents' Benefits

Application for Fatal Dependents' Benefits

Authorization and Request for Unemployment

Average Weekly Wage Certification

Average Weekly Wage Certification-Concurrent

Average Weekly Wage Certification-Post Injury

Average Weekly Wage Computation Schedule

Average Weekly Wage Worksheet

Choice of Doctor

Choice of Doctor (Spanish)

Claimant's First Notice of Death and Claim for Compensation

Direct Deposit and Debit Card Authorization Form

Direct Deposit and Debit Card Authorization Form - Sample Version ONLY

Employee Report of Occupational Injury or Illness to Employer

Employee's Claim for Compensation / Report of Initial Treatment

Employee's First Notice of Accidental Injury and Claim for Compensation.

Employee's First Notice of Occupational Disease and Claim for Compensation

Employee's Notice of Accidental Injury or Occupational Disease

Employee's Notice of Accidental Injury or Occupational Disease

Employee's Notice of Rejection of Terms of the Arizona Workers' Compensation Law

Employee's Notice of Rejection of Terms of the Arizona Workers' Compensation Law

Employee's Wage Report

Employees Claim and Employer First Report of Injury

Employees Notice of Injury and Claim for Compensation

Employees' and Physicians' Report of Occupational Hearing Loss

Employees' and Physicians' Report of Occupational Injury or Disease

Employees' Report of Occupational Pneumoconiosis

Employer First Report of Injury / Fatality

Employer First Report of Injury or Disease

Employer Report of Employee Earnings - formerly Wage Statement (C-94A)

Employer Report of Employee Earnings - formerly Wage Statement (C-94A) (Spanish)

Employer Report of Occupational Injury or Illness to Division of Workers' Compensation

Employer's First Report of Alleged Occupational Injury or Disease

Employer's First Report of Injury

Employer's First Report of Injury

Employer's First Report of Injury

Employer's First Report of Injury Must be submitted electronically.

Employer's First Report of Injury or Illness

Employer's First Report of Injury or Illness

Employer's First Report of Injury or Occupational Disease

Employer's First Report of Injury or Occupational Disease

Employer's First Report of Injury or Occupational Disease