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FORMS

Insurance Information

  • Accident, Sickness & Workman’s Compensation Claims Directions
  • Death Benefit Plan Summary

Forms

  • First Report of Injury
  • Provident A&S Claim Form
  • Culpeper County WC A&S Claim Filing Instructions
  • Membership Update
  • Membership Termination Notification
  • Employer’s Accident Report
  • Exposure Form Package
  • Provident First Claim Notice
  • Supervisor’s Investigation Report
  • Light Duty Application
  • Death Benefit – Beneficiary Designation
  • Death Benefit – Claim
  • Death Benefit – Beneficiary Statement

Accident, Sickness and Workman’s Compensation Claims Directions

In the event of a claim, please follow the following steps:

1. Please contact the Fire, Rescue Resource Administrative Assistant within 24 hours of injury:
Kimberley Toone, ktoone@culpepercounty.gov
Cell: (540) 229-4463
 
2. At your earliest convenience domplete the online claim form (there is no paper form) with Travelers at:

www.travelers.com/reportaclaim/#/claimtype

The Immediate Supervisor must complete the Supervisor’s Incident Investigation Form and submit to the Fire, Rescue Resource Administrative Assistant within 24 hours.

Injured member must have Light Duty documentation completed and signed by the Health Care Provider after each visit.