The best time to gauge the value of your insurance is when you have a claim. Claims are administered by Gallagher Bassett Services, Inc.. When you have a claim, call the Gallagher Bassett toll-free line, 800-821-5401 and ask for the Occupational Accident Claims Department. A claims representative will provide prompt, courteous service.

If you need a medical claim form, an initial disability claim form, or a supplemental disability claim form, one can be printed or downloaded here:

Medical Claim Forms (choose applicable form)

• California (PDF: 32 KB)
• Florida (PDF: 32 KB)
• Illinois (PDF: 32 KB)
• New Hampshire (PDF: 32 KB)
• New Jersey (PDF: 32 KB)
• New York (PDF: 32 KB)
• Pennsylvania (PDF: 32 KB)
• Rhode Island (PDF: 32 KB)
• All other states (PDF: 32 KB)

Disability Forms

• Initial Disability (PDF: 25 KB)
• Supplemental Disability (PDF: 21 KB)