Claims Kit

For your convenience and to help you comply with the law, we compiled the forms you’ll need to file a claim in an electronic Claims Kit (PDF). The chart below lists the forms and when to distribute them. You can also view and download the individual forms below:

Forms to File A Claim	Policy Inception	Time of Injury
Workers’ Compensation Claim Form e3301 with instructions
Employer’s Report of Occupational Injury or Illness e3067 Must be completed and submitted to State Fund no later than 5 days from the date of knowledge of a work injury or illness.
Employee’s Guide to the State Fund Medical Provider Network e13176 Must be posted at every worksite in a location that is easily visible to your employees. Must also be provided to employee at time of injury or, where there is existing injury, and when transferring care into MPN.

Please refer to the Employer Requirements Page for a list of documents required to post and distribute to employees at the Time of Policy Inception and at the Time Of Hire.

Call Us
If you have additional questions, please call our Customer Service Center at (877) 405-4545.