Claims - Statewide Insurance Fund

Claims Reporting

Workers Compensation

Click Here to Report Workers Compensation Claims Online

If you prefer, you can download the form, complete it, and submit it via fax.

First Report of Injury
File Size:	59 kb
File Type:	pdf

Incident Only
File Size:	128 kb
File Type:	pdf

Member Property and Automobile Claims

Complete the form and select submit. Please be advised that claims can only be submitted by Fund Members or their Risk Manager. According to NJ Statute Title 59 Claims Against Public Entites, third party claims against a public entity needs to be reported directly to the public entity. This form is not for third party claim filing.

Fund Member: *

Contact Name *

First

Last

Email *

Phone Number *

-

-

Select Claim Type *

Automobile Property

Date of Loss *

Description of Property or Vehicle Involved *

Location of Damaged Property or Vehicle *

Line 1

Line 2

City

State

Zip Code

Country

Please describe the cause of loss. *