Contact Us  |  April 25, 2017

Workers' Compensation Claim

To expedite the processing of your claim, please complete this notice with as much information as you have available.
Contact Information
Name: *
Daytime Phone Number: *
Fax Number:
Email:
Best Time to Call: *
Insured Information
Company Name:
Address:
City:
State:
Zip Code:
Injury Information
Injured Party Name: *
Date of Injury: *
Accident Location: *
Brief description of accident/injury: Include any equipment being used and activity being performed during the accident. *
Witness Information
Please enter name, address, and daytime phone numbers for each witness.
Additional Comments
Please enter any additional comments you feel we need to know about this claim.
* = Required Field
You will be contacted by a representative of Marsh & McLennan Agency LLC (formerly Kinker-Eveleigh Insurance Agency) within 24 hours of our receipt of this form. If you do not hear from us, please call our office at (513) 248-4888. Please note that submission of this form does not constitute notice of a claim to either Marsh & McLennan Agency or your respective insurance company until confirmed by Marsh & McLennan Agency or your insurance company.