Get Insurer/self-insurer Contacts

Filling out the INSURER/SELF-INSURER CONTACTS form is crucial for enabling effective communication regarding workers' compensation claims. This guide provides detailed instructions to assist users in completing this form accurately and efficiently.

Follow the steps to successfully fill out the INSURER/SELF-INSURER CONTACTS form

1. Click ‘Get Form’ button to obtain the form and open it in an online editor.
2. Enter the WCB case number and claim administrator claim (carrier case) number in the designated fields. Ensure that these details are accurate, as they are essential for processing your request.
3. In section A, provide the patient's name, date of injury or illness, social security number, and address. Also, include the employer's name and address alongside the insurer's name and address.
4. Complete section B by entering the attending doctor's name and address, their WCB authorization number, and contact information, including telephone number and fax number.
5. In section C, state the date the request is submitted. Detail the treatment or procedure requested and reference the appropriate guideline. Make sure to indicate the injury and/or condition in the first box and the corresponding section of the medical treatment guidelines in the remaining boxes.
6. If applicable, attach any supporting medical documentation related to the date of service and enter your comments in the designated section.
7. In section D, enter the designated fax number or email address for the insurer's contact. If this information is not available, check the appropriate box provided.
8. Sign the form in the designated area, ensuring that your signature reflects your intent to authorize the request. Please include the date of submission.
9. After completing the form, verify that all sections are accurately filled. Save changes made to the document, and you may opt to download, print, or share the form according to your needs.

Start completing your INSURER/SELF-INSURER CONTACTS form online now.