Workers' Compensation Custom Claims Report Your Name*Your Title*Your Email Address* Entity Name*Which categories would you like contained in you customer report (check all that apply)* By Claim Number By Year of Loss (ex: all claims from 2006) By Date Claims Were Added/Reported By Specific Date of Loss By Claimant Name By Entity Name By Department By Employee Status (FT, PT, Seasonal) By Claim Status (i.e. Open, Closed, Reopened) By Injured Body Part By Accident Description (i.e. MVA, Slip and Fall, etc.) By Claims with a Value Above (see field below) By Claims with a Value Below (see field below) By Number of Days the Claim Has Been Open Medical Only Claims Indemnity Only Claims Value AboveValue BelowWhat Date Do You Need Your Report By?* MM slash DD slash YYYY *Please allow a minimum of 24 hoursThis field is hidden when viewing the formUsername Δ
