CLAIM REPORTING

Emergency Claim Reporting Procedures
Please click HERE

Please click below for the
applicable claim form.

Workers' Compensation Claim Forms

(Effective January 1, 2021, the Managed
Care Provider is Qual-Lynx)

Accident Investigation Report Form
Dear Valued Client:
For the workers' compensation claims, Accident
Investigation Reports are required to be
completed by the employee's supervisor and
emailed to Qual-Lynx.  Attached is a fillable
version of the Accident Investigation Report form
that is readily saved in your computer to
facilitate completion of the required information.

Please click HERE for this form.

Kindly share this fillable form with your Claim
Coordinators.  The completed Accident Investigation
Report should be emailed to froi@qual-lynx.com.

Initial reports of workers' compensation
claims should continue to be reported to Qual-Lynx
at 1-877-822-9368.

Workers' Compensation Injury Reporting Procedure - click HERE

Workers' Compensation Emergency Posting Notice - click HERE

First Pharmacy Visit form - click HERE

Auto Loss and General Liability forms
Auto Loss Notice- fill-in form

Auto Loss Notice- standard form

General Liability Notice- fill-in form

General Liability Notice- standard form

Once the form is complete, please
email the completed form to:
Don Kellerman, Liability Unit Manager
Phone: 609-833-2174
dkellerman@qual-lynx.com

Property Loss forms
Property Loss Notice- fill-in form

Property Loss Notice- standard form

Once the form is complete, please
email the completed form to:
Joseph Lisciandri, Property Supervisor
Phone: 609-601-3191
Fax: 609-601-3192
jlisciandri@qual-lynx.com

Please click HERE for a complete
listing of your Qual-Lynx
Account Service Team.

MEL EPL/POL Help Line for
Employment Related Issues
click HERE