Claims Applications

All applications and forms can be downloaded. Please complete the appropriate application/form and fax it back to our offices. Please note that Adobe Reader is required to view these forms.

Texas Fax: (713) 880-7166

Arkansas Fax: (479) 649-0534

If you have any questions regarding the correct form, please click here.

Employer's Wage Statement

Download now - Employer's Wage Statement                               

Employer's Illness or Injury Report

Download now - Employer's First Report of Injury or Illness                               

Supplemental Report of Injury

Download now - Supplemental Report of Injury                                

You will need the Adobe Acrobat Reader to view or print these files. You can view or print PDF's just by clicking on the PDF you wish to examine. If you wish to download the file from Internet Explorer, point your mouse over the Application and right click and select "Save Target As...".

For a free download of Adobe Acrobat Reader, click the image below.