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W orkers Compensation Internet Reporting https://claimzone.com/reporter/logout.do ID: artexclaim Password: reportclaim Gallagher Bassett Client Number: 004118. Gallagher Bassett Services, Inc. Initial Screen. Enter Date of loss or click on Calendar and click New Claim.

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Gallagher Bassett Services, Inc

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Gallagher bassett services inc

Workers CompensationInternet Reportinghttps://claimzone.com/reporter/logout.doID: artexclaim Password: reportclaimGallagher Bassett Client Number: 004118

Gallagher Bassett Services, Inc


Gallagher bassett services inc

Initial Screen

Enter Date of loss or click on Calendar and click New Claim.

Can also search for a report by entering data in the Search Criteria section and clicking on Search.


Preliminary detailed questions

Preliminary/Detailed Questions

The date of loss is pre-filled.

The Insured, Employer, Reporting Location, Questionnaire, Language and Social Security Number may be pre-filled or selected from a dropdown.


First report of injury employer

First Report of InjuryEmployer

State appears here.

Offers several dropdown options and pre-fills.


Carrier

Carrier

Carrier/claims administrator information prefills.


Employee

Employee

Last Name is REQUIRED.

Social Security Number is pre-filled


Occurrence

Occurrence

Date of Injury is pre-filled.

Enter detailed information about injury.


Treatment

Treatment

Can enter Hospital and/or Physician.


Additional info

Additional Info

Can click on the ‘link’ view to maneuver through the application

Can enter Preparers Name, Title, Company and Phone Number.

Click on the thumbnail sketch to enlarge and view a copy of the First Report.


Addendum

Addendum

Contact Name and Phone Number are REQUIRED.


Review edit employer carrier employee occurrence treatment additional info and addendum

Review/Edit Employer, Carrier, Employee, Occurrence, Treatment, Additional Infoand Addendum

Have option to edit and review each section of the form prior to submission.


Review edit employer carrier employee occurrence treatment additional info and addendum continued

Review/Edit Employer, Carrier, Employee, Occurrence, Treatment, Additional Info, and AddendumContinued

MUST click Finish to submit form.

SAVE will only save the form to be completed later. SAVE will not submit form.


Submission of first report

Submission of First Report

Print first report of injury.

Provides Claimants Name, Date of Loss and Reference Number.

Click OK to go back to initial screen.


Gallagher bassett services inc

IMPORTANT

PRINT a copy of Employer’s First Report of Injury form by using the Printer icon in the top right corner of the confirmation page.

If you entered an email address into the email address field on the Client Specific Questions screen, you will receive an emailed confirmation that the report has been received and is being processed.

The completed first report of injury will be electronically processed into the Gallagher Bassett systems within minutes and provided automatically to the appropriate workers’ compensation adjusting branch.


Questions

Questions?

If you have any questions or need further training, please contact Cindy or Melissa.

Cindy Kuschel, Monday through Friday,

8:30 a.m. – 4:30 p.m. Central

Phone: 630-285-4235

[email protected]

Melissa Pazmino, Monday through Friday,

8:30 a.m. – 4:30 p.m. Central

Phone: 630-285-3405

[email protected]


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