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Oklahoma
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Home
CLIENTS
LHCSIF
LADA-SIF
LHBA GL Trust
SELF-INSURED
Oklahoma
OKLAHOMA
REPORT A CLAIM
LOUISIANA
OKLAHOMA
Loss Prevention
CONTACT
ABOUT
OUR TEAM
SERVICES
INDUSTRY LINKS
WORKERS
Report a claim online
Name of contact person reporting injury
*
First Name
Last Name
Contact number for person reporting injury
*
Policy Name
*
Policy Number
*
Date of accident
*
MM
DD
YYYY
Injured employee's name
*
First Name
Last Name
Occupation/job title of injured employee
Injured employee's address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Injured employee's phone number
SSN
Injured employee's date of birth
MM
DD
YYYY
Sex
Male
Female
Other
Hire date
MM
DD
YYYY
Wage rate
Employment status
*
Full-Time
Part-Time
Not Employed
On Strike
Disabled
Retired
Unknown
Apprenticeship Full-Time
Apprenticeship Part-Time
Volunteer
Seasonal
Piece Worker
Description of accident
*
Location of accident
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Last work date
*
Date returned to work
*
Date employer was notified of accident
*
Thank you!
