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  • Po Box 3151 Charleston Wv 25332

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Ant s Name (First, Middle, Last) 2. Claimant s Address (Street or P.O. Box, City, State, Zip) 3. Claimant s Social Security Number 4. Date of Injury 5. Claim Number 6. Provider s Name (please print) 7. Authorization Number 8. Address of Point of Departure (need physical address or closest route number) 9. Address of Point of Destination 10. Time of Departure 11. Time of Return a.m. 12. Purpose of Travel p.m. a.m. p.m. Medical procedure codes to be used below in column 14:.

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Related content

West Virginia Workers' Compensation Employees' and...
West Virginia Workers'. Compensation Employees' and ... Date: /. /. BrickStreet Mutual...
Learn more
ENCOVA INSURANCE INJURY KIT
Encova Insurance. P.O. Box 3151. Charleston, WV 25332-3151. Or fax to: 877-898-6980...
Learn more

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Options for reporting a claim: Call 844-362-6821, and select “policyholder” and option 1. Email the First Report of Injury to claimsintake@encova.com. Fax the First Report of Injury to 877-293-5513 or 304-941-1151.

Encova Insurance's NAICS: 52,524 How many employees does Encova Insurance have? Encova Insurance has 1,200 employees What industry does Encova Insurance belong to?

Encova Insurance offers insurance products including commercial, life and personal insurance.

All West Virginia employers are statutorily required to maintain workers' compensation insurance coverage. Visit the West Virginia Offices of the Insurance Commissioner Employer Coverage Unit online to file workers' compensation.

Encova Insurance Competitors & Alternatives Competitor NameRevenueTotal Funding#2 Insurance Partn...$10.3MN/A#3 Knight Insuranc...$8.8MN/A#4 EyeMed Vision C...$148.2MN/A#5 Trimble Insuran...$3.2MN/A6 more rows

Background on BrickStreet and Motorists BrickStreet Insurance, a mutual company owned by its policyholders, became West Virginia's first private workers' compensation carrier on Jan. 1, 2006.

As Encova, we are now a top 20 mutual insurance carrier with over $4 billion in assets.

Motorists Life, Encova Insurance's life insurance company, has been rebranded as Encova Life.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232