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New Hampshire

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 800.364.6662. 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 employee’s 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.

Complete the Employer’s Report of Occupational Injury or Disease Form (8WC)

All claims, regardless of treatment, must be reported to the State of New Hampshire Department of Labor. The First Report must be filed as soon as possible after knowledge of any occupational injury or disease, but no later than five days thereafter.

If the employee’s incident resulted in four or more calendar days of incapacity to earn full wages, then a Supplemental Report of Injury Form (13 WCA) must also be filed with the Department of Labor no later than seven days after the date of injury. Please note that late reporting may result in a fine being levied by the New Hampshire Department of Labor.

Please mail the original forms or fax a copy to:

The State of New Hampshire, Department of Labor
P.O. Box 2077
Concord, NH 03302-2077
Fax (603) 271-6149

All forms, including the Employee Incident Report, Supervisor Investigative Report, First Report of Injury and Supplemental Report of Injury must also be reported to Atlantic Charter Insurance Company.

Please mail the original forms or fax a copy to:

Atlantic Charter Insurance Company
Attn: Claims Department
25 New Chardon Street
Boston, MA 02114
Fax (617) 488-6502