File a Claim
Providing the level of service you have come to expect from us is our highest priority. As we work to ensure the health and safety of our employees we are also experiencing an increase in call volume. We are encouraging our customers to use our online claim reporting website to report a new claim. It's an easy, safe and secure process to report a claim. Please click "Report your claim online" below now to report your new claim.
Starting at the end of January 2024, it will be mandatory to provide Social Security numbers and dates of birth when reporting new workers' compensation claims.
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Online
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Telephone
Nurse Hotline for Injured Employee: Use our 24/7 nurse triage hotline, when no medical treatment has been sought, by calling 844-322-4662.
Important note: If your organization is located in ND, OH, WA, or WY please use the phone number provided to you directly from Medcor.
All other Claims: To report a claim for first time, please call 800-554-2642. Claims representatives are available to assist you during our normal business hours of 7:00am until 6:00pm CST Monday through Friday. We also remain on call round-the-clock and may be reached through our after-hours answering service
Before you call, it is helpful if you have your account/policy number, a description of the claim, and phone numbers for key contacts which will allow claims representatives to process your claim promptly. -
Fax
Claims reporting forms are included with every Church Mutual policy. You can fax these forms - or forms you download from our website - to Church Mutual's Claims Department at (715) 539-4651.
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Mail
Claims reporting forms are included with every Church Mutual policy. You can mail these forms - or forms you download from our website - to us at:
Church Mutual Insurance Company, S.I.
P.O. Box 342
Merrill, WI 54452-0342
If your claim involves water damage or bodily injury, we recommend that you do not submit the claim through traditional mail. Any delay in reporting these claims can lead to more extensive damage. -
Email
All new claims should be emailed to ClaimsIntake@churchmutual.com. This is a dedicated email address box for newly reported claims and ensures the timely and efficient creation and assignment of your new claim. Continue sending mail and other claim related material for established & previously reported claims to claims@churchmutual.com
If you'd like to email a form to us, please download from our website and email to claimsintake@churchmutual.com
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Claims Forms
Property Loss Report
For damage to any of your property except vehicles.
Accident Report
For Injury or property damage to others that may have been caused by you or your organization.
Automobile Accident Report
For injury or damage caused in an auto accident.
Workers' Compensation (forms by state)
For injury to an employee.
For New York customers only:
NEW! DD-1 Form - New York Direct Deposit Requirements/Form
To receive your payment via electronic fund transfer, please complete and return the Direct Deposit Authorization form. If you choose to split your benefits between accounts you must complete a separate form for each account you would like your benefits distributed to and include the amount to be placed in each account.
Once your request has been received, it may take up to three weeks to process. If additional information is needed your adjuster will contact you. The forms, or any claim documentation, can be sent with a clearly noted claim number via fax, email, or mail.
For California customers only:
NEW! SB 1159 - California Workers’ Compensation Reporting Requirement for COVID-19 | Form Instructions
If you are notified of a Covid-19 diagnosis that is not alleged to be work related:
For each case, complete a separate SB 1159 form, attached, and send to Claimsintake@churchmutual.com.
If you are notified of a Covid-19 diagnosis that is alleged to be work related by the employee:
- 1. Complete SB 1159 form that is attached.
- 2. Complete Form 5020 — Employer's Report of Occupational Injury or Illness.
For each case, complete both forms and email to Claimsintake@churchmutaul.com
If you previously reported a Covid-19 claim, after July 5th, and the SB 1159 form has not been completed:
Complete the SB 1159 form and send to Claimssupportcompliance@churchmutual.com. Follow this process for each case of this type. Be sure to include the claim number on the SB 1159 form.
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