Report a Claim

The steps below are all mandatory in reporting a claim and must be completed within 24 hours of the incident.
  1. Highmark Insurance Group Website
  2. Employer Checklist
  3. Employee Acknowledgement Form
  4. Workers’ Comp Physician Panel
  5. Authorization for Disclosure of Health Information
  6. Employee Questionnaire
  7. Occupational Injury & Disease Form
  8. Work Activity Status Form - to be completed by Physician
  9. Workers’ Comp Pharmacy Network
  10. Medical Treatment Waiver
  11. Accident Investigation Form - (Building Principal/Immediate Supervisor)-Generate a PDF of this form. Retain for your records and email a copy to susan-vitulli@esasd.net (Click File, Print, select CutePDF Writer and click OK).
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