Hospitality Insurance Business Insurance Life & Health Insurance Homeowners Insurance Automobile Insurance Home Page Like Us on Facebook Home Page Get A Quote Policy Changes File A Claim Make a Payment Contact UsValley Agency

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
Required
Last Name
Required
Business Name
Required
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
E-Mail Address
Required
Injured Employee Information
Date/Time Injury Occurred
Required
First Name
Required
Last Name
Required
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
Social Security Number
Required
Did injury occur on Employer's premises
Required
Date Employer Notified
Required
/ /
Describe the Incident
Required
Describe Injuries
Optional
Initial Treatment
Required
Physician Seen (if applicable)
Optional
Hospital or Offsite Treatment Facility (if applicable)
Optional
Sex
Required
Date of Birth
Required
/ /
Marital Status
Required
Dependants
Required
Date Hired
Required
/ /
State in which employee was hired
Required
Job Title
Required
Employment Status
Required
Average Weekly Wage
Required
Time Employee began work on date of injury
Required
Submission Validation
Required
CAPTCHA
Change the CAPTCHA codeSpeak the CAPTCHA code
 
Enter the Validation Code from above.
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.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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