MagMutual Insurance Company

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***This form contains protected health information which must be protected and safeguarded. This form may only be transmitted by a secure, encrypted email system. If you do not have a secure, encrypted email system, DO NOT email this form to MagMutual. You may call the Claims Department at 1-800-586-6891.***

If you are reporting a workers’ compensation incident, please report via service.magmutual.com or email the First Report of Injury to alliedlinesclaims@magmutual.com.
PolicyOwner Information
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Person Submitting Report
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Date Matter Reported*
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Date Matter Occurred*
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Type of Matter*
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- Deposition Request
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MagMutual Insurance Company

PolicyOwner Information

Person Submitting Report

Patient Information