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Worker's Compensation Form

Click here to download the form for reporting a workers compensation claim. Once you have filled out and completed the form, email the completed form to or fax it to (888) 678-4077.

If the state where you were injured differs from your home address, please use the following guide to determine which State FROI form to use:

  1. State hired = Iowa

  2. State you live ___________________

  3. State injured ___________________


Choose the state that has 2 matches above. If all 3 responses are different, then choose the state you would anticipate the majority of

medical care to occur.

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