Workers' Compensation Toolkit

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This kit is provided to new workers' compensation policyholders and their agents, as well as to all current policyholders when their policies renew. It contains important claims department contact information, instructions, and forms.

Harleysville Insurance
PO Box 244
Harleysville, PA 19438-0244
(888) 595-9876
Fax: (800) 441-4118

Agribusiness Mailing Address for Claims Related Mail
P O BOX 182066
Columbus, OH 43218-2066
Phone: (800) 228-6700
Fax: (800) 842-1482

Nationwide Insurance Medical Provider Billing (only):
Nationwide Insurance Company
Attn: DSPF-68
PO Box 182068
Columbus, OH 43218-2068

Some Nationwide companies are not licensed in this state.

Below are a few additional tools to help you manage your workers' compensation claim:

Locate medical providers - Are you an employer or injured worker looking for doctors, hospitals or pharmacies? We can help you find local medical professionals.

First Fill program - The First Fill program allows one-time prescription processing before a workers' compensation claim is established, resulting in no out-of-pocket cost for the injured worker. Ask your claims representative for more details.


NOTE: If you experience difficulty opening/accessing the PDF's using the links below:

Open to access the documents

Nevada Compliance Information

Posting Requirements

Reporting Of Claim By Employer

Penalties for Late Reporting

Physician Selection

Posters and Publications

POSTER - Informational Poster - Displayed by Employer - 11 x 17 Size Required

Poster Regulations Required

BROCHURE -Brief Description of Your Rights and Benefits if You Are Injured on the Job Required

BROCHURE - Notice to Employees - Tip Information

BROCHURE - Employee's Guide

BROCHURE - Employee's Guide (Spanish)

BROCHURE - Employer's Guide

EMPLOYERS: What Should I expect from my insurer?

Employer Frequently Asked Questions


Employer's Report of Industrial Injury or Occupational Disease

Notice of Injury or Occupational Disease (Incident Report)

Employee's Claim for Compensation / Report of Initial Treatment

Wage Calculation Form for Claims Agent's Use

Fatality Report Required

Employer's Wage Verification Form

Alternative Choice of Physician or Chiropractor

Please Note: The information on this site is maintained by a third-party, Nationwide does NOT warrant or represent that the information will be error-free. Your use of the site is on an as-is basis, at your sole discretion and risk. The site is for informational purposes, and nothing included in the site shall replace the need for qualified legal counsel. We recommend that you consult with legal counsel, agents, or risk managers regarding workers' compensation obligations.

This service uses a proprietary system to pre-fill certain claims office and insurance company data on some forms. This may prompt a request by your Adobe Reader program to "trust" the source of the files. Please designate this as a trusted source in order for that information to be pre-filled for you.

The documents in this system use Adobe Reader to view PDF files. If you do not have Adobe Reader, you may download the latest version here for free. Download Adobe Reader Here