Worker's Comp - 1st Report of Injury

Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Business Information

First Name *

Last Name *

Business Name *

Street *

City *

State *

ZIP / Postal Code *

Primary Phone Number *

E-Mail Address *

Injured Employee Information

Date/Time Injury Occurred *

First Name *

Last Name *

Street *

City *

State *

ZIP / Postal Code *

Primary Phone Number *

Date of Birth *

Social Security Number *

Sex *

Marital Status *

Dependants *

Date Hired *

State in which employee was hired *

Job Title *

Employment Status *

Average Weekly Wage *

Time Employee began work on date of injury *

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Date Employer Notified *

Did injury occur on Employer's premises *

Describe the Incident *

Describe Injuries

Initial Treatment *

Physician Seen (if applicable)

Hospital or Offsite Treatment Facility (if applicable)

Submission Validation

Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

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Valley Agency Company
(717) 264-4311
797 Fifth Avenue - Chambersburg, PA 17201