ACHE Online Form

FILE AN IIR

Your submission will generate a notice to some rep who will review this notice and contact you. If you are not contacted and have questions, please call us at 1-800-IAM-HURT.

The following fields are encrypted for your security. The ACHE Online Form is a 3 step process. The fields below do not accept special characters such as: < > ~ | or ,

COMPANY'S POLICY INFO

*Company Name:
*Policy Number:
*Type of Business:
*County:
End of step 1. Go to step 2.

DATE, TIME OF DAY AND LOCATION OF ACCIDENT

*Street Address:
*City, Town or Village:
*Zip Code:
*State:
*County:

*Do you expect your injured worker to lose pay or work time?

INJURY DESCRIPTIONS *How did the accident or exposure occurred?

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