The Intelligent Insurance Solution

Notice to Employees

We strongly encourage all our members and self- insured clients to take advantage of this option in order to protect your rights as an employer and provide a defense against unsubstantiated and frivolous claims that previously could not be defended because the notice did not get to the right place and therefore was not responded to within a 28 day period.  
In order to designate a reporting contact, complete the form below to assign the appropriate Title and/or Department in your organization to whom all formal notice of claims should be delivered to.  As there is much staff turnover, we are not looking for a particular name of an individual, but a job title or department name. We will then complete the form for you and send you a revised Notice to Employees to post in your company locations. Unlike the current posting, this one is to be printed on legal size white paper, and does not need to be on cardstock. This new notice replaces the current one that you are using which should be removed.



Please designate a particular job title and/or department where all Form30Cs should be sent

Organization Name : *
(42 characters long)
Policy Number :
(5 characters long)
Job Title or Department where you want the Form 30Cs to be submitted : *
Physical Address : *
(46 characters long)
City : *
(46 characters long)
State : *
(2 characters long)
Zip : *
(10 characters long)
Phone : *
(13 characters long)
Name of Person Completing Form : *
Title : *
Email : *