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Berkley Net Underwriters, LLC - File A Claim
File A Claim
Please fill out the form below:
Claims may also be reported via phone to 800.435.1127 or via fax to 866.275.6320
Insured Name*
Policy Number*
Insured Contact Name*
Insured Contact Phone*
Injured Employee Name*
Injured Employee SSN
Injured Employee Address
Address Continued
Injured Employee Phone
Injured Employee Date Of Birth
Injured Employee Date Of Hire*
Average Number of Hours Worked per Week*
Last Date Paid
Date of Accident or Injury*
Time of Accident or Injury
Date Accident/Injury Reported to Employer*
Type of Injury*
Body Part Injured
Where did Accident/Injury Occur?*
Description of Accident/Injury*
Has Injured Employee Sought Medical Treatment?*
Yes
No
Has employee returned to work?*
Yes
No
Are there any circumstances that are suspicious or questionable about the report of this injury?
Yes
No
Claim Submitted By*
Phone Number*
Email Address*
Additional Comments*
  (*required)
 

Report via Phone
800.435.1127

Report via Fax
866.275.6320


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