Step # 1: Submit First Report Injury Form
The First Report of Injury form must be submitted in a TIMELY manner*. Just use our quick and easy ONLINE First Report of Injury Form and you are finished in just minutes. You will receive a confirmation that your First Report of Injury submission was successful.
If you prefer to fax or mail the First Report of Injury form, see "Alternative Methods for Reporting an Injury".
If you have a panel list of physicians that includes the appointment scheduling services by Premier Comp Solutions please be advised that scheduling an appointment is NOT the same as reporting the injury. You must submit a First Report of Injury form to Lackawanna Insurance Group.
* FILE WITHIN TIMELY MANNER: The Pennsylvania Bureau of Workers'™ Compensation ONLY accepts electronic injury reports from Insurers and requires submission of an injury report within 48 hours for injuries resulting in death and within 7 days for all other injuries. If you have not submitted your claim already, please do so immediately.
For Lackawanna Insurance Group to timely report injuries to the Pennsylvania Bureau of Workers' Compensation the insured must immediately after an injury complete and submit our First Report of Injury Form. It is necessary to complete at least the required fields on our First Report of Injury Form since this information is required by the Pennsylvania Bureau of Workers'™ Compensation.
In addition to reporting the injury (First Report of Injury form), please fax or mail their signed Workers' Compensation Information, Employee Notification and Authorization forms from the Claims Kit.
Claims Kit & Forms
- FULL Employer Claims Kit
- Required Authorization & Notification Forms (This PDF contains ALL required forms, including: Workers'™ Compensation Information, Employee Notification and Release Authorization forms)
- First Report of Injury (Form ONLY)
- Workers'™ Compensation Information Form (English) (Spanish Version)
- Workers'™ Compensation Employee Notification Form (English) (Spanish Version)
- Authorization to Release Information (English) (Spanish Version)
- Claims Reporting Procedures
For expediency, please submit completed forms via fax. However, you MUST still mail originals!
FAX TO: Lackawanna Insurance Group @ 570-824-7969
MAIL CLAIM FORMS TO:Lackawanna Insurance GroupPO Box 270Wilkes Barre, PA 18703
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