Report a Claim

The steps below are all mandatory in reporting a claim and must be completed within 24 hours of the incident.
  1. Brickstreet Website
  2. WC-ERCKLST - Employer Checklist
  3. WC-EECKLST - Employee Checklist
  4. WC-EE001 - Employee Acknowledgement Form
  5. WC-EE002 - Employee Medical Treatment Form
  6. WC-EE003 - Employee Medical Records Release Form
  7. WC-EE004 - Employee Incident Report Form
  8. WC-EE005 - Workers’ Comp Physician Panel
  9. WC-EE006 - Workers’ Comp Pharmacy Form
  10. WC-EE007 - Work Activity Status Form – To be completed by Physician.
  11. WC-EE008 - Online Services Claim Filing Form - This form may be completed by employee and used to complete online submission by employer.
  12. 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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