MENU Safety National » Claims Expertise » Medical Management Medical Management Safety National provides a team of expert nurses and medical management analysts to help provide oversight of medical treatment to injured workers, mitigate medical exposure and maximize medical outcomes. Policyholders receive resources to assist with: Pharmacy benefit management Large bill review Home modifications Administration of MSAs Contact Us Claims Success Stories Claim Management Medical Management How to Report a Claim Claims Forms First Report Claim COVID-19 First Report Claim (Online Form) COVID-19 First Report Claim (Fillable pdf) © 2021 Safety National®. A member of the Tokio Marine Group. All Rights Reserved. Employee Access | Legal | Privacy | Canadian Compliance

MENU Safety National » Claims Expertise » COVID-19 FIRST REPORT COVID-19 FIRST REPORT (Non-Hospitalization Claims Only) Insured: (required) Assoc. Member No: (If applicable): Policy number Policy period start date Policy period end date SIR: Date of loss: Accident State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Washington DC Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennslyvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Claim #: Claimaint(s): Date of birth: Marital Status: SingleMarried NCCI Job Class Code: Job Description: Has a COVID-19 test come back positive? YesNo This Claim: Has been investigated and found compensable. *Additional information may be requested separately.Has been investigated and is denied.Currently remains under investigation. Additional Pertinent Information: Form Completed By: Date Completed: Company: Address: Phone: Fax: Email: Please attach the Employer’s First Report of Injury and all pertinent file material. (10mb max) << Home Corporate Office: 1832 Schuetz Rd St. Louis, MO 63146 Toll Free Phone: 888-995-5300 Local Phone: 314-995-5300 © 2021 Safety National®. A member of the Tokio Marine Group. All Rights Reserved. Employee Access | Legal | Privacy | Canadian Compliance