Claims

Report a claim.

Tell us what happened and we will immediately get to work on your claim.

Coverage is underwritten by Clear Spring Property and Casualty Group. Claims are administered by Cannon Cochran Management Services, Inc. (CCMSI).

If this is a medical emergency, call 911 first.

Policy issued by American Liberty Insurance Company (ALIC)? See ALIC claim reporting.

How to report

Phone

1-844-975-3466

Toll-free claim reporting.

[email protected]

Attach your completed report of injury form.

Fax

1-217-477-5452

Include a cover page with your contact details.

Online

Report of injury form

Complete the form below.

Before you contact us

Complete the Report of Injury form in full to ensure prompt handling of your claim.
Submit the completed form by email or fax using the details above — or online below.
Have the policy number, date of loss, and a brief description of the incident ready.

Prefer paper? Download the Report of Injury form (PDF) · Word version

Workers’ compensation report of injury form

Fill out this form in detail. Answer all questions to assure prompt handling of your claim. Fields marked * are required.

1Employee personal information

Full name *Required.

Date of birth *Use MM/DD/YYYY.

Address *Required.

Phone *Enter a valid phone number.

Sex Male FemalePlease choose one.

Social Security number: for your security, do not enter your Social Security number on this website. The claim professional will collect it directly when they contact you.

2Employment information

Job title *Required.

Name of employer *Required.

Employer’s address *Required.

Employer’s phone number *Enter a valid phone number.

Date of hireUse MM/DD/YYYY.

DepartmentRequired.

Supervisor nameRequired.

Number of days per weekRequired.

Number of hours per dayRequired.

Hourly wage rate or salaryRequired.

3Injury information

Date of injury *Use MM/DD/YYYY.

TimeRequired.

Date injury reported *Use MM/DD/YYYY.

Name of the person the accident was reported to *Required.

Exact location of the accident (be specific) *Required.

Describe the accident *Required.

What part of the body was injured? *Required.

Who witnessed the accident?Required.

4Medical treatment information

Where was medical treatment first sought?Required.

Lost time from work? Date of first day missedRequired.

Current treating doctor nameRequired.

Doctor’s phoneEnter a valid phone number.

Doctor’s addressRequired.

Next appointment dateUse MM/DD/YYYY.

Prior workers’ compensation claim or compensation received? Yes NoPlease choose one.

If yes, please describeRequired.

5Person submitting this report

Policy numberRequired.

Your name *Required.

Your role *Required.

Your phone *Enter a valid phone number.

Your email *Enter a valid email.

I confirm the information in this report is true and complete to the best of my knowledge. *Please confirm before submitting.

A claim professional will be assigned promptly and will contact you to confirm receipt and next steps.

Less common

American Liberty Insurance Company (ALIC) claims

If the policy was issued by American Liberty Insurance Company (ALIC), do not use the CCMSI contacts or form above. Report ALIC claims using any of the following:

Web

benchmarkadministrators.com

[email protected]

Phone

800-362-5198

Not sure which company issued the policy? Check the policy declarations page, or ask your agent.