Type of Claim: Workers Comp

Please fill in applicable fields (* denotes required field). Once completed, please click Submit Claim at the bottom of this form. A claims adjuster will contact you shortly.

For emergency claims requiring immediate attention occurring after hours (evenings, weekends or holidays) please contact a Cumberland Representative by telephone at 1-800-232-6992.

Policy Symbol (ex. HON):*
Policy Number (ex. 1234567):*
Policyholder/Employer Name:*
Name of Person Reporting Claim:*
Employer Mailing Address:*
Street:
City:
State:
Zip:
Location of Accident:*
Street:
City:
State:
Zip:
Employee Name:*
Employee Home Address:
Street:
City:
State:
Zip:
Employee Information:
Date of Birth:
Occupation/Job Title:
Date of Injury/Illness:*
  MM DD YYYY
/ /
Type of Injury/Illness:
Primary Contact Name:*
Secondary Contact Name:
Primary Contact Telephone:*
Secondary Contact Telephone:
1.
2.
Description of Damages (What Happened?):*
Email Address:
Agency:
Did the Injury/Illness Exposure Occur on the premise of the employer?
Delaware Fraud Statement: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.
New Jersey Fraud Statement: Any person who knowingly and with intent to defraud any insurance Company or other person files an application for insurance or statement of claim containing any materially false information, or conceals, for the purpose of misleading, information concerning any fact material thereto, is subject to criminal and or civil penalties.
Pennsylvania Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
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