File a Claim

This form should not be used to file workers' compensation claims. Workers' compensation claims must be directly filed with the carrier within 24 hours of the event. 


Click Here to File a Workers Compensation Claim


Need to file a claim? Mountain State Insurance Agency is here to help you. Don't wait- it's important to contact us as soon as you are able to report your claim! 

Please fill out this form with some basic information in order for us to help you start the claims process. For assistance, please contact our Claims Specialist, Carrie Weitzel, at (304) 341-1217 or


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.