Alternative Methods for Reporting an Injury

In order to expedite your claims, we strongly recommend that you use quick and easy ONLINE First Report of Injury Form.  The online form It only takes a few minutes and you will receive an email confirmation that your First Report of Injury was successful.

 

However, if you cannot complete the online form, you may also download, complete and submit the forms via fax and/or mail.

 

Step #1A: Download First Report Injury Form (PDF)

 

DOWNLOAD: First Report of Injury form (PDF)

 

NOTE: Please remember to also include the additional forms from your Claims Kit: Authorization & Notification Forms

 

 

Step #1B: Submit First Report Injury Form

 

For expediency, you may submit completed forms via fax.  However, you must still mail originals!

FAX TO: Lackawanna Insurance Group @ 570-824-7969

 

MAIL TO:

Lackawanna Insurance Group
PO Box 270
Wilkes Barre, PA 18703

If you cannot fax the completed form, you may mail the form. However, the First Report of Injury form must be submitted in a TIMELY MANNER (as noted in Step #1 of How to File a Claim).

 

PROCEED TO STEP 2