Notice:

The purpose of this service is to share basic claim information with Mountain State Insurance Agency in order to start the claim process. Completion of this form does not report a claim with any insurance carrier. After submission of this form, a representative of Mountain State Insurance Agency will contact you to collect any additional necessary information and then will submit a claim to the appropriate carrier on your behalf.

This form should not be used to file workers’ compensation claims. Workers’ compensation claims should be filed directly with the carrier.