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.
How to File a Workers Compensation Claim