CNA Insurance
Online Loss Reporting   

Workers’ Compensation Loss

General Instructions

When submitting a report, please complete the entire Web Loss Report Form and provide all required information. Required fields are marked in bold.

  • You can open/close any section of this form at any time by clicking a gray section header below.
  • If the mandatory information is unknown at the time of your web submission, enter “unavailable” in any field requiring text.
  • Enter all 999s in any fields that require a number value. The final report will depend on the accuracy and completeness of the information you are able to provide.
  • No information will be transmitted until you click the “submit” button at the bottom of the form.
  • The Accident Description field will have a 200-character limitation. Additional information can be entered in the final remarks area of the submission. Additional Remarks will have a 200-character limitation.

Emergencies

If your loss is severe, CNA recommends that you phone in your loss to ensure that it receives the immediate attention it needs. All Commercial Insureds should call our toll-free number at 877-262-2727.

1. Date & Time of Injury
Date of Injury: (MM/DD/YYYY)    Time of Injury:  
2. Person Reporting
First Name:      Last Name:
Address:
City:     State:      Zip: -  
Telephone Number: - -      Secure Fax Number: - -
Relationship to Insured:
I am a (choose one):
Supervisor's Telephone Number: - -
3. Insured Information
Insured Name (Company Name):
I use a DBA (Doing Business As) Name:
Address:
City:     State:      Zip: -   
Telephone Number: - -
Location Code:
Policy Number:       Effective Date: (MM/DD/YYYY)
On to Next Step >>
4. Loss Location Information
Did Incident Occur on Employer's Premises:
Enter Address Where Loss Occurred:
Address:
City:     State:      Zip: -   
State in Which Claim Should Be Filed:
On to Next Step >>
5. Employee/Employment Information
First Name:      Last Name:
Address:
City:     State:      Zip: -
Telephone Number: - -     Date of Birth: (MM/DD/YYYY)
Social Security Number:      Gender:
Marital Status:      Number of Dependent Children:
Job Title:      Date of Hire: (MM/DD/YYYY)      Employment Status:
State Hire Date (if not hired in current state): (MM/DD/YYYY)      Pay Type:
Wages Per Hour:      Annual Salary (if not hourly):
Department Employee Works:      Supervisor ’s Name:
Days Worked Per Week:      Hours Worked Per Day:
Time Employee Began Work:       Was Employee Performing Regular Job?
Date Employer Notified of Injury: (MM/DD/YYYY)
Has Employee Missed Time from Work Beyond Their Normal Shift:
If Yes, Expected Date Returned to Work: (MM/DD/YYYY)      If Yes, Last Day Worked: (MM/DD/YYYY)
Date Disability Began: (MM/DD/YYYY)     Did Employee Return to Work:
If Yes, Actual Date Returned to Work: (MM/DD/YYYY)      Did Salary Continue After the Injury:
Did the Employee Receive Full Pay for the Date of the Injury:
On to Next Step >>
6. Incident Description
Loss Type:
Injury Description (include body part and type of injury):
Initial Treatment:
Does the Employer question the claim validity?
If Fatality, Give Date of Death: (MM/DD/YYYY)
Does insured agree with the injury/incident description?
7. Medical Information
Provider Name:
Address:
City:     State:      Zip: -
Telephone Number: - -
Admitted to Hospital:   If Yes, Hospital Name:
On to Next Step >>
8. Witness Information
Were There Any Witnesses to the Incident:
Witness Name:
Address:
City:     State:      Zip: -
Telephone Number: - -
On to Next Step >>
9. Contact Information
First Name:      Last Name:
Telephone Number: - -     Cell Phone Number: - -
Your Email Address:
If you wish to receive a claim acknowledgement, please enter a secure fax number to send to: - -
10. Additional Remarks
Enter any additional remarks you would like to make in the space below: