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Pay Online
Agent Login
Get A Quote/Find An Agent
Upload Your Audit Documentation
Safety Resources
Find Your HBA
News
Resources
Contact
Pay Online
Agent Login
Get A Quote/Find An Agent
Upload Your Audit Documentation
Safety Resources
Find Your HBA
News
Resources
Contact
✕
Claim Reporting Questionnaire
Home
Claim Reporting Questionnaire
Claim Reporting Questionnaire
Employer/Insured Contact Information
Company Name
*
LHBASIF Policy Number
*
Person Completing Form
*
Phone
*
Fax
Email
*
Is Company A Drug Program Participant & Do You Have A Written Drug Policy?
Injured Worker Information
Name
*
Date of Birth
*
MM slash DD slash YYYY
SSN #
*
Gender
*
Marital Status & Number of Dependents
*
Address
*
Phone Number (With Area Code)
*
Job Title/Occupation
*
Class Code
*
Hire Date
*
MM slash DD slash YYYY
Type Of Employee
*
Direct
Sub
Employee of Sub
Other
Full Time or Part Time
*
Full Time
Part Time
Accident and Medical Information
Accident Date & Time
*
Address of Accident, Job Site
*
Description of Accident / What Activity When Injured
*
Part of Body Injured and Nature of Injury
*
Fracture, cut, burn, sprain, etc.
Who Did Employee Report to & When?
*
Advise if Accident Due to Faulty Equipment, No Fault Motor Vehicle Accident, etc
*
List Any Witnesses to Accident
*
Has Employee Returned to Work?
*
Yes
No
When?
*
MM slash DD slash YYYY
Name & Location of Medical Facility Where Treated
*
Overnight Stay in Hospital?
*
Yes
No
Was Drug Testing Requested/Done?
*
Yes
No
Results of Drug Test
*
Explain if You Question Validity of Accident
*
Have You Been Contacted by an Attorney?
*
Yes
No
Attorney Name
*
Additional Comments or Information
Δ
Member Admin Credentials
Sign Up
Homebuilders SIF is pleased to announce the creation of an all-new online platform through which multiple services and features will be offered to Fund Members. The online platform will enable Homebuilders SIF to more efficiently protect Fund Members by providing access to payroll and claim information, key policy documents, and important updates. Access may be achieved by identifying an authorized representative of your company to serve as an Administrator. In order to register someone as an Administrator, please provide us with the following information:
LHBA-SIF Policy #
(Required)
Company Name
(Required)
Administrator Name
(Required)
First
Last
Administrator Email
(Required)
Administrator Telephone
(Required)
NOTE:
Administrators will have the authority and capability
to view sensitive information associated with each Member's account, including claim information.
Administrators can set up other users, assign rights, and may also restrict viewing access. Administrators should be carefully selected by each Member accordingly.
Should you have any questions please feel free to contact us at:
1-225-387-0286.
Consent
(Required)
I certify that I consulted with at least one individual who owns or co-owns the Member company named above, that I am duly authorized to act for all purposes as an Administrator on behalf of the Member named above relative to the online portal of Homebuilders SIF. I also certify that all information provided to Homebuilders SIF through this online portal will be true, accurate, and correct to the best of my knowledge. I understand and acknowledge that important communications may be conveyed by or to each Administrator through the online platform and the email address provided, and I am duly authorized to participate in such communications on behalf of the Member.
(Required)
Δ
