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Preferred Customer Connect

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Preferred Forms Library

Thanks for visiting our Preferred forms library. This page provides you with many of the required forms that you will need to submit information to us or other regulatory agencies.

If you would like to order paper forms, Click here

Materials Request Form

To obtain claims kit or Medical Provider Network (MPN) materials, simply complete the form below and press the submit request button.

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Name*
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Mailing Address*	123 Alpha St., San Diego CA 92108
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	Available Printed Materials	Quantity
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If you have any questions, please call us at (888) 472-9001 and press 2 for customer care.

Complete the form and the materials will be mailed to you.

Click on the menu items below to navigate to the various sections of the library

To view/print pdf files, you will need the Adobe Acrobat Reader, free for download at:

Claims

Claims Reporting

5020 First Notice of Injury or Illness Form
DWC-1 Employee Claim Form & Notice of Potential Eligibility

Medical Provider Network & Posting Notices

DWC-7 Notice to Employees – Injuries Caused by Work
Medical Provider Network Posting Notice

Other Claim Resources

Fraud Poster email or call us

Safety & Health

OSHA Form 300A – Summary of Work-Related Injuries and Illnesses
Cal OSHA Form 300A
Cal OSHA Form 300

What would you like to do?

Report A Claim Find a Doctor Forms Our MPN Info Return to Work Claims Kit Contact our VP of Claims

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If you're a PEI broker, please contact your broker/agency administrator

If you're a policyholder, please email policy services at [email protected].

Preferred Employers Insurance Company P.O. Box 85478, San Diego, California 92186-5478, Phone: (888)472-9001

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