Forms - CM Regent

Pennsylvania Forms

Choose from the drop down menus below to find and download claim forms, instructions, checklists and user kits for Pennsylvania. The PDF forms will require Adobe Reader^®.

For Wisconsin materials, please contact Kasey Baker by email or by phone at (717) 790-2322.

Pennsylvania - Property and Liability

ACORD Auto Loss Notice

ACORD Notice of OCC Claim

ACORD Property Loss Notice

Claimants Report of Accident

Driver’s Statement

General Authorization

PIP Application

PIP Attending Physicians Form

PIP Wage and Salary Verification Form

Statement of Loss

Witness Report of Accident

Witness Statement

Pennsylvania - Workers' Compensation

What to do if you are injured at work

WorkComp Claims Process Timeline

WorkComp Glossary

WorkComp Internal Work Related Incident Form

WorkComp Medical Authorization Form

WorkComp Notice to Employees

WorkComp PA Managed Care Rights Duties Form

WorkComp Physical Capabilities Form

WorkComp Provider Panel

WorkComp School Posting For Claims Submission

WorkComp Users’ Kit

WorkComp Transitional RTW Duty Form

Pennsylvania - Dental, Vision and COBRA

COBRA Enrollment Notification

COBRA Retiree Benefit Payment Reminder

Fringe Benefits Enrollment/Change

LASIK InfoSheet

NVA Benefit Summary

Dental Claim Form

Vision Claim Form

Pennsylvania - Life and Disability

Accelerated Benefits Form

Accidental Dismemberment

Beneficiary Designation

Group Life Insurance Claim Form – Claimant

Group Life Insurance Claim Form – Employer

Life Disability Waiver of Premium – Employee

Life Disability Waiver of Premium – Employer

Life Disability Waiver of Premium – Physician

LTD Claim Form – Employee

LTD Claim Form – Employer

LTD Claim Form – Behavioral Health Physician

LTD Claim Form – Physician

LTD Voluntary Premium Statement

Evidence of Insurability Application

Notice of Conversion Privilege

Short Term Disability Claim Form – Employee

Short Term Disability Claim Form – Employer

Short Term Disability Claim Form – Behavioral Health Physician

Short Term Disability Claim Form – Physician

Survivor Family Form

Voluntary Life Age Chart

Voluntary Life Premium Statement

Risk Control

Accident General Investigation Form

Instructions for Risk Management Forms

Inspection Checklists

Slip Trip Fall Investigation Form

Strain Injury Investigation Form

Who We Are

CMRegent Insurance Company

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CM Regent Solutions

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