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Click ‘Get Form’ to open the Liberty Mutual Claim Form in our editor.
Begin by filling out your personal information in the 'TO BE COMPLETED BY EMPLOYEE' section. Include your name, address, phone numbers, and Social Security number.
Indicate your marital status and provide details about your spouse or domestic partner if applicable. List any dependents under age 19 who are unmarried.
In the 'HOSPITAL' and 'DOCTOR' sections, enter the names and contact information of all treating physicians. Be sure to include dates related to your injury or illness.
Answer questions regarding your occupation-related injury and any Workers’ Compensation claims you may have filed.
Detail any other income sources you are receiving or have applied for, including amounts and dates.
Review all entered information for accuracy before signing at the bottom of the form. Ensure you understand the legal implications of your submission.

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