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Pennsylvania Forms

Choose from the drop down menus below to find and download claim forms, instructions, checklists and user kits for Pennsylvania. The PDF forms will require Adobe Reader^®.

For Wisconsin materials, please contact Kasey Baker by email or by phone at (717) 590-8008.

Pennsylvania - 2019 Applications

2019 PA Package New Business Application

2019 PA Package Renewal Application

2019 Drone Application

2019 Vacant Building Application

2019 PA SLL New Business Application

2019 PA SLL Renewal Application

2019 PA Workers' Compensation Application

2019 PA Privacy Application

Pennsylvania - Claim Forms

ACORD Notice of Occ Claim

ACORD Auto Loss Notice

Claimants Report of Accident

Group Life Insurance Claim Form

WorkComp Internal Work Related Incident Form

WorkComp Medical Authorization Form

WorkComp Physical Capacities Form

WorkComp Transitional RTW Duty Form

Dental Claim Form

Vision Claim Form

Pennsylvania - Property and Liability

ACORD Auto Loss Notice

ACORD Notice of Occ Claim

ACORD Property Loss Notice

Claimants Report of Accident

Driver’s Statement

General Authorization

PIP Application

PIP Attending Physicians Form

PIP Wage and Salary Verification Form

Statement of Loss

Witness Report of Accident

Witness Statement

Pennsylvania - Workers’ Compensation

WorkComp Claims Process Checklist

WorkComp Claims Process Timeline

WorkComp Contact List

WorkComp Glossary

WorkComp Internal Work Related Incident Form

WorkComp Medical Authorization Form

WorkComp Notice to Employees

WorkComp PA Managed Care Rights Duties Form

WorkComp Physical Capacities Form

WorkCompProvider Panel

WorkComp School Posting for Claims Submission

WorkComp Users' Kit

WorkComp Transitional RTW Duty Form

Pennsylvania - Dental, Vision and COBRA

COBRA Enrollment Notification

COBRA Retiree Benefit Payment Reminder

Fringe Benefits Enrollment/Change

LASIK InfoSheet

NVA Benefit Summary

Dental Claim Form

Vision Claim Form

Pennsylvania - Life and Disability

Accelerated Benefits Statement

Accidental Death Statement

Beneficiary Designation

Beneficiary Tips

Employee Application

GL Premium Statement

Group Life Conversion Form

Group Life Insurance Claim Form

Group Life Supplemental Premium Statement

Life Disability Waiver of Premium

LTD Conversion Form

LTD Premium Statement

Medical Underwriting HIPAA Authorization Release

Notice of Conversion Privilege

Portability Form

STD Premium Statement

Survivor Family Form

Supplemental Life Age Chart

Risk Control

RiskMgmt Accident General Investigation Form

RiskMgmt Instruction Form

RiskMgmt Safety Committee Inspection Checklists

RiskMgmt SlipTripFall Investigation Form

RiskMgmt Strain Injury Investigation Form

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Pennsylvania accounts only

Dental
Visit United
Concordia

Vision
Visit NVA

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