Print Claim 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 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

If you are notified of a Covid-19 diagnosis that is alleged to be work relatedby the employee:

  1. 1. Complete SB 1159 form that is attached.
  2. 2. Complete Form 5020 — Employer's Report of Occupational Injury or Illness.

For each case, complete both forms and email to

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 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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Church Mutual Insurance Company, S.I. (a stock insurer)
P.O. Box 357 | 3000 Schuster Lane | Merrill, WI 54452-0357
Telephone (800) 554-2642 or (715) 536-5577

© 2024 Church Mutual Insurance Company, S.I. All rights reserved. Protecting the Greater Good is a registered trademark of Church Mutual Insurance Company, S.I.

Church Mutual is a stock insurer whose policyholders are members of the parent mutual holding company formed on 1/1/20. S.I. = a stock insurer.