New Hampshire Claim Forms
EMPLOYERS New Hampshire Claim Kit (click here to download)
The adjusting of the claims in this state are handled by Broadspire. Once a claim is reported to EMPLOYERS, the report will be sent to Broadspire for assignment. Below is the contact information for Broadspire:
P.O. Box 14133 Lexington, KY 40512-4133
Toll free: 800-258-9546
New Hampshire Required Postings & Forms
Please post the following notices, both in English and Spanish, in a conspicuous location frequented by employees such as the break room, lunchroom or time clock. If you have multiple office locations be sure to post the notices at each location.
- Anti-Fraud Notice (English and Spanish)
- Notice of Compliance (English and Spanish)
- Workers Right to Know
The following forms need to be completed and submitted to EMPLOYERS when a work-related injury occurs:
- Employer’s First Report of Injury or Occupational Disease (Form No. 8WC). As soon as you have been notified of a work-related injury, please immediately fill out this form and submit it to EMPLOYERS and provide a copy to the employee. Please use this form to notify EMPLOYERS of every work-related injury or disease suffered by an employee, regardless of severity.
- Employer’s Supplemental Report of Injury (Form No. 13 WCA). This report, indicating disability of an employee of four or more days, shall be filed as soon as possible after date of knowledge of an occupational injury or disease, but no later than ten days thereafter. This report shall also be submitted upon employee’s return to work.
- Wage Schedule (Form No. 76 WCA). This form enables the Claim Examiner to calculate the correct compensation that may be owed to an injured employee. Please complete the form and submit it to EMPLOYERS and provide a copy to the employee. Policyholders must forward to the Insurance Carrier a copy of this wage schedule or a printout of gross wages no later than the employee’s fifteenth day of disability resulting from the industrial accident per LAB 506.02(b).
- Supplemental Wage Schedule (Form No. 76 WCA 1). This form is to be completed only when indemnity rate is based on after-tax earnings as defined by RSA 281-A:2, 1-a.
- Notice of Accidental Injury or Occupational Disease (Form No. 8aWCA). This is an optional form utilized to give the injured worker the opportunity to describe, in his or her own words, how the injury occurred. This form is to be completed by the injured employee and used by the employer to complete the Employer's First Report of Injury or Occupational Disease (8WC). The Notice of Accidental Injury or Occupational Disease (8aWCA) is the only form that the injured employee should complete.
- Accident Investigation Report. This basic accident form should be completed by the employee’s supervisor/manager as soon as possible after the accident. Please send the report to the following EMPLOYERS address as soon as it has been completed by the supervisor/manager: EMPLOYERS Claim Department, P.O. Box 32036, Lakeland, FL 33802-2036. You should keep a copy on file for your records.
- New Hampshire Employers Guide to Workers’ Compensation
- Off-Site Transitional Duty Program - Helping Your Injured Employees Get Back to Work
A successful transition back to work relies on the collaborative efforts of the manager/supervisor, the injured employee and their adjuster. As a manager/supervisor, learn what you can do to help facilitate a successful return to work.