Workers’ Compensation Employee Report of Injury Form

In the event of an injured employee, you must fill in all required fields on the “Employer's Basic Report of Injury” form and call (833) MCC-LOSS (833-622-5677) and be prepared to provide the Gallagher Bassett Intake Specialist this information. At the end of the call, you will be given a Loss Number that can be referenced in future correspondence. This number can be called 24/7 for your convenience.

If you are unable to call it in, fill in the required fields and email it to but you will not receive an immediate Loss Number this way.

Please note: There is no longer an option to mail in the form. Only submit the loss using one of the options above.

If you have any questions about the form or need assistance with the loss or injured employee, contact Karen Hissong, Claims Manager at Gallagher Bassett Services at (517) 318-8108 or email her at

As always, if you have any questions or concerns, please do not hesitate to call the Risk Management Department at (517) 372-9310 or (800) 395-5565.