About Us Services Report a Claim Contact Us

Home > Report a Claim

Need to file a claim? Start here

Simply complete the Incident Report Form as accurately as possible and send it to us. You may either complete the electronic form below or download the faxable form, complete it, and fax it to 516.535.4984.

Upon receipt of your form, an RMPG representative will contact you within 24 hours to confirm the information and file the necessary paperwork with the appropriate agencies. If you need assistance, please feel free to contact the RMPG Claims Service Center at 1.888.767.4492.

Please note, the fax form requires a PDF reader. To use this form you must have the Adobe Acrobat Reader installed on your PC. The Adobe Reader is free and can be downloaded from Adobe at http://www.adobe.com/products/acrobat/readstep.html.

The electronic form below may be completed using your Internet browser. Simply fill in the information as accurately as possible and press the "Submit Claims Form" button at the end of the form.


********* Incident Report Form *********

* Indicates required information. You must complete the designated fields.

   Date of Accident:* 

Submitter Information

1. Your Name: *

2. Your Email Address: *

 

3. Your Phone Number: *

A. Employer Information

1. Employer: *

2. Employer FEIN: 

3. Mailing Address: *

4. Location Address (if different): 

5. Phone Number: *

6. Nature of Business or Industry Code: 

7. OSHA Case Number (if known): 

8. NY UI Employer Reg Number: 

B. Insurance Carrier / Self-Insured Employer

   If individually self-insured, enter your Board W Number and skip to Section C.

1. Board W Number: 

2. Carrier Group Name: 

3. Policy Number: 

     Policy Period: 

From:           To:   

4. If Carrier Unknown, Insurance Agent Name: 

5. Phone: 

C. Employee's Personal Information

1. First Name: *

    Middle Name: 

    Last Name: *

2. Date of Birth: *

3. Mailing Address: *

    City*, State*, Zip Code* 

       

4. Social Security Number: *

5. Contact Phone Number: *

6. Gender: *

D. Employee's Injury or Illness

1. Time of day employee began work on date of injury: 

:

2. Time of injury: 

:

3. Has the employee given you notice of injury illness?: *


    If yes, notice was given to: *

    

    Date Noticed Provided: *

4. Have you given the employee a Claimant Information Packet? *

    If Yes, give date: 

5. Where did the injury / illness happen?    (e.g. 1 Main St., Pottersville, at the front door) 

6. Was this location where the employee normally worked? 

    If No, why was the employee there?

7. Employee's Supervisor: *

8. Did Supervisor see injury happen? *

9. Did anyone else see the injury happen? *

    If Yes, give name(s) *

10. What was the employee doing when he/she was injured or became ill?    (e.g., unloading truck, stocking a truck, stocking a shelf, typing annual report) *

11. How did the injury occur?    (e.g., the employee tripped over a pipe and fell on the floor) 

12. Explain fully the nature of the employee's injury/illness; list body parts affected    (e.g., twisted left ankle and cut to forehead) 

13. Was an object (e.g., forklift, hammer, acid) involved in the injury/illness? 

    If Yes, what was it? 

14. Was the injury the result of the use or operation of a licensed motor vehicle? *

    If Yes, 

    License Plate Number (if known): 

    If employer's vehicle was involved give name and address of your motor vehicle insurance carrier: 

15. Did the injury/illness result in the employee's death? 

    If Yes, what what the date of death? 

    Name and address of nearest relative: 

E. Medical Treatment

1. What was the date of the employee's first treatment? 

2. Where did the employee receive first medical treatment for this injury/illness? 




    Who treated the employee and where? 

3. Is the employee still being treated for this injury/illness? 

    If Yes, name and address of treating doctor(s): 

4. To your knowledge, did the employee have another work-related injury to the same body part or a similar illness while working for you? 

    If yes, name the doctor(s) who treated the previous injuries/illness (if known): 

F. Return To Work

1. Did the employee stop work because of his/her injury/illness? *

    If Yes, on what date? *

2. Has the employee returned to work? *

    If Yes, on what date? 

3. If the employee has returned to limited duty what are his/her average gross earnings per week? 

G. Employee's Work Information on the date of the injury or illness

1. Date the employee was hired: 

2. What was the employee's job title?: 

3. What types of activities did the employee normally perform at work?  (Attach job description if available): 

H. Employee's Payroll Information on the date of the injury or illness

1. Employee's gross pay in average week was? 

2. Did the employee receive lodging or tips in addition to pay? 

    If Yes, describe: 

3. Employee's job was (check one): *

4. Which days of the week did the employee usually work? *

5. Was the employee paid for a full day on the day of the injury/illness? 

6. Did you continue to pay the employee after the injury/illness (e.g., sick leave, vacation, disability, regular salary)? 

I. Additional Information






 

Industry Resources | Legislative Updates

Corporate Headquarters | Mineola, NY