Workers’ Compensation Loss

General Instructions

When submitting a report, please complete the entire Web Loss Report Form and provide all required information. Required fields are marked in bold.

Emergencies

If your loss is severe, Beacon Mutual recommends that you phone in your loss to insure that it receives the immediate attention it needs. Please call our toll-free number 888-886-4450.

1. Person Reporting
First Name:      Last Name:
Department:
Address:
City:     State:      Zip: -  
Telephone Number: - -      Secure Fax Number: - -
Relationship to Insured:
2. Insured Information
Insured Name (Company Name):
Address:
City:     State:      Zip: -   
Telephone Number: - -     Fax Number: - -
DBA Name:
Nature of Business:     State Unemployment ID:
Location Code:
Policy Number:       Effective Date: (MM/DD/YYYY)
3. Loss Location Information
Did Incident Occur on Employer's Premises:
Enter Address Where Loss Occurred:
Address:
City:     State:      Zip: -   
State in Which Claim Should Be Filed:
4. Employee/Employment Information
First Name:      Last Name:
Address:
City:     State:      Zip: -
Telephone Number: - -     Date of Birth: (MM/DD/YYYY)
Social Security Number:      Gender:     Preferred Language:
Marital Status:      Number of Dependent Children:
Job Title:      Date of Hire: (MM/DD/YYYY)      Employment Status:
State Hire Date (if not hired in current state): (MM/DD/YYYY)      Pay Type:
Wages Per Hour:      Annual Salary (if not hourly):
Department Employee Works:      Supervisor’s Name:
Days Worked Per Week:      Hours Worked Per Day:
Time Employee Began Work:       Was Employee Performing Regular Job?
Date Employer Notified of Injury: (MM/DD/YYYY)
Has Employee Missed Time from Work Beyond Their Normal Shift:
If Yes, Last Day Worked: (MM/DD/YYYY)
Date Disability Began: (MM/DD/YYYY)    Did Employee Return to Work:
If Yes, Actual Date Returned to Work: (MM/DD/YYYY)      Did Salary Continue After the Injury:
Did the Employee Receive Full Pay for the Date of the Injury:
5. Incident Description
Date of Injury: (MM/DD/YYYY)    Time of Injury:  
Loss Type:     Activity Engaged In:
Injury Work Process:
Injury Description (include body part and type of injury):
Do you agree with the description of the accident?
Safeguards/Safety Equipment Provided:     Safeguards/Safety Equipment Used:
Initial Treatment:
If Fatality, Give Date of Death: (MM/DD/YYYY)
6. Medical Information
Provider Name:
Address:
City:     State:      Zip: -
Telephone Number: - -
Admitted to Hospital:   If Yes, Hospital Name:
7. Witness Information
Were There Any Witnesses to the Incident:
Witness 1 Name:
Address:
City:     State:      Zip: -
Telephone Number: - -
Witness 2 Name:
Address:
City:     State:      Zip: -
Telephone Number: - -
Witness 3 Name:
Address:
City:     State:      Zip: -
Telephone Number: - -
8. Contact Information
First Name:      Last Name:
Telephone Number: - -
Job Title:
Address:
City:     State:      Zip: -
Where to Contact:     When to Contact:
9. Additional Remarks
Enter any additional remarks you would like to make in the space below: