Claims (Patriot Risk Services)

Claim Forms
New Claim Packet

Use: Employer should follow the claim protocol, and fill out the 5020 and Supervisor's Investigation Report. The rest of the forms should be given to the injured employee. Upon receipt of the forms from the employee, the employer should fill out the bottom section of the DWC-1, while the employee completes the Supervisor's Investigation Report. The paperwork should be reviewed to make sure it is completely and correctly filled out and then faxed to 954-252-3816 or emailed to The 24hr call center can be reached at 866-993-0239

Declination of Medical Treatment Packet

Use: Some employees do not wish to pursue treatment for a variety of reasons, however, a DWC-1 must still be given to the employee. The declination is verification for employer records. If in the future the employee seeks Workers' Compensation benefits, the employee should then fill out the DWC-1 and notify the employer.
First Aid Packet

In any incident where only first aid treatment is provided, the employer should review the first aid guidelines and reporting requirements, then fill out the 5020, Supervisor's Investigation Report and fax them to 954-252-3816 or emailed to If the claim is a first aid it will not affect the experience modifier.

You may access the list of Network Providers through the following website:  You may search for providers by zip code, name or location.

General and Professional
Workers Compensation
Employment Practice
Liability Insurance (EPLI)

Shomer Insurance Agency, Inc
Lic #OC79888
4221 Wilshire Boulevard
Suite 222
Los Angeles, CA 90010

Phone: (323) 934-8160
Fax: (323) 934-8170

Copyright © 2010. Shomer Insurance Agency, Inc.