MagMutual Insurance Company

Confidential attorney work product in anticipation of litigation or claim, subject to peer review privilege.

***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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Mid-Atlantic Women’s Care consists of over 30 OB/GYN facilities and 6 Imaging Centers throughout the Hampton Roads community

Corporate Office
757-455-8833

Corporate Office
6353 Center Drive, Suite 100
Norfolk, Virginia 23502

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Phone Number *	Secondary Number

Phone Number *	Secondary Number

MagMutual Insurance Company

PolicyOwner Information

Person Submitting Report

Patient Information