Report a Claim

The following steps should be taken when a work-related injury or incident occurs.

Complete the Employee Incident Report

Please note: In the event of a catastrophic claim, contact Atlantic Charter Insurance Company immediately at 617.488.6500. This report should be completed jointly by the employee’s supervisor and the injured employee.

  • Section 1
    
General Information

    Section 1 documents general information about the employee, when and where the incident occurred, who was involved, what treatment has occurred, and the current work status.

  • Section 2
    
Employee’s Statement

    Section 2 should be completed by the injured employee. Only the employee should write a detailed statement explaining what occurred and what injury resulted. The employee should then sign the statement where it is indicated.

  • Section 3
    
Employee’s Medical Authorization

    Section 3 is a medical release which the employee should be asked to sign. This release allows Atlantic Charter Insurance Company to access medical information pertaining to the injury which the employee is alleging.

Determine if the incident will result in five or more calendar days of incapacity

Incidents that require medical treatment, but result in less than five calendar days of incapacity are considered “Medical Only” claims. They should be reported to Atlantic Charter Insurance Company via the Employee Incident Report. Please include any other supporting documentation. Notice to the state/Department of Industrial Accidents is not required.

A Form 101 Employer’s First Report of Injury or Fatality must be filled out for any injured employee who is incapacitated and unable to earn full or partial wages for five or more calendar days. The days do not need to be consecutive. The form must be filed with the Department of Industrial Accidents within seven calendar days, not including Sundays and holidays.

Effective January 1, 2014, please be advised that Atlantic Charter Insurance Company and its affiliates began filing Form 101 with the DIA on your behalf.

For your convenience, an electronic copy of the Form 101 can be accessed via our homepage. A printed, completed copy of the Form 101 must be sent to Atlantic Charter Insurance Company (using the methods described in the adjacent box), given to the injured worker, and kept with your file.

Please note that late reporting by the employer may result in a fine being levied by the Department of Industrial Accidents.

The Employee Incident Report and Supervisor Investigative Report must also be submitted to Atlantic Charter Insurance Company.