Continental Claims
Worker's Compensation Assignment Form


Please complete and submit the following information regarding your worker's compensation assignment

Your assignment will be sent to our Facility for processing by our nearest branch office.

NOTE: Fields marked with an asterisk (*) are required.
 Submitted By Contact Information  
First Name:*
Last Name:*
Phone:*
Fax:*
E-mail:*

 Submitted By Company Information  
   
First Name:*
Last Name:*
Company Name:*
Street Address:*
Street Address (cont):
City:*
State / Province:*
Zip / Postal code:*
Contact Phone:*
Contact Fax:*
Contact E-Mail:*

 Coverage  

 Loss Information  
  Please use MM/DD/YYYY format

Date of Accident:*

Customer Claim #:
Location of Accident:

Brief Description of Loss:*


 Employer Information  
Employer / Insured:*
  Please use MM/DD/YYYY format
Date Accident Reported
to Employer:*
Employer Contact First Name:
Employer Contact Last Name:
Employer Address:
Employer Address (cont):
City:
State / Province:
Zip / Postal code:
Employer Work Phone:

 Claimant Information  
Claimant First Name:
Claimant Last Name:
Claimant Address:
Claimant Address (cont):
City:
State / Province:
Zip / Postal code:
Claimant Home Phone:
Claimant Work Phone:
Male / Female:
Social Security Number:
Date of Birth:
Occupation:
Investigation Type:
Action(s) to take /
Special Instructions:
   
Preferred Method of confirmation
from CCS:
 
Please click the Submit button only ONCE. It may take a few minutes for your claim to be processed. You will receive a confirmation once your assigment has been sent.