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Claims Forms

Below are the links to Workers' Compensation Claims Forms

Friedlander Group Client Portal offering secure 24/7 online claims reporting and reports

Workers’ Compensation C-2 Claim Form

  • Employers Report of a Work Related Injury or Illness. If one of your employees has a work-related injury or illness, you should complete and submit this form to Friedlander Group, or file the claim directly through your Client Portal

C11 Form

  • Employers Report of Injured Employee's Change in Employment Status Resulting from Injury. Change in employment status includes return to work, discontinuance of work, increase or decrease of regular hours of work and increase or reduction of wages

C240 Form

  • Employer's Statement of Wage Earnings for 52 Weeks

C107 Form

  • Employers Request for Reimbursement 

Claimant Information Packet

  • Information to provide employees when they have a workers' compensation claim

Claimant Information Packet in Spanish

  • Información para proporcionar a los empleados cuando tienen un reclamo de compensación para trabajadores

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