CLAIMS

Our Claims are handled in-house and the department is structured to accommodate the complex needs of our insureds. Our staff of experienced adjusters is committed to providing prompt, unsurpassed service and responsiveness that our clients require. Our dedication to quality backed by superior service has positioned USSIC as an innovative leader in the occupational injury adjusting industry.

Claims Kit
Thank you for choosing U.S. Specialty Insurance Company (USSIC) as your Primary Employer's Indemnity carrier. Click on the link above for your Claims Kit containing the necessary documents to report a claim. The Claims Kit is a critical component of your insurance program. By completing the reporting forms correctly, USSIC will be able to handle your claims in the most efficient manner.

The Claims Kit includes the following reporting forms:

• First Report of Injury (English) or First Report of Injury (Spanish) - This document is required to begin the claims handling process. The First Report of Injury provides USSIC notice that a workplace injury has occurred. It is critical that this document be completed and faxed or emailed to USSIC within 24 hours of the loss.
• Employee Statement (English) or Employee Statement (Spanish) - to be completed by the employee
• Supervisor's Report (English) or Supervisor's Report (Spanish) - to be completed by the supervisor
• Witness Statement (English) or Witness Statement (Spanish) - to be completed by the witness, if any
• Medical Authorization (English) or Medical Authorization (Spanish) - to be signed by the employee
• Declined Medical Treatment (English) or Declined Medical Treatment (Spanish) - to be signed by the employee if he/she declines treatment
• Wage Statement (English) or Wage Statement (Spanish) - If an employee is anticipated to be off of work for more than seven days, this document needs to be completed to determine the employee's average weekly salary. Wage replacement will be 75% of the employee's average weekly salary, up to a maximum of $600 per week.

Please feel free to contact the Claims Department with any questions, comments, or concerns or email/fax the above referenced reporting forms using the following contact information:

Telephone: (888) 688-0775
Fax: (713) 744-9675
Email: peiclaims@ussic.com

U.S. Specialty Insurance looks forward to developing a long and pleasant working relationship with you.

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