Claims Kit

7710 Insurance’s management team is committed to providing you with cost effective coverage and personalized service to meet your workers’ compensation insurance needs.


1 North Cantey Street, Suite 106
PO Box 207
Summerton, SC 29148
Toll Free: (844) 200-7710
Email: claims@7710insurance.com


How to use this kit:

STEP #1: Display Posting Notices in area accessible to ALL employees:

  • Notice of state Workers’ Compensation Law

STEP #2 Report job-related injuries when it occurs:

  • Seek medical treatment for injured worker – as soon as possible after injury occurs.
  • Report work-related injury either by phone (844-200-7710) or by email.

STEP #3 Provide the injured worker with the following:

  • Medical Provider List
  • Authorization to Release Protected Health Information form

What to do when an injury occurs:

  1. MEDICAL TREATMENT immediately refer injured worker to closest directed care medical clinic or emergency room!

    CAUTION!!!

    In the event that an injured employee appears or seems to be unable to drive himself to a clinic, for any reason, the supervisor or another employee should assist that injured worker and inform another employee to call 911.

  2. REPORT YOUR WORK-RELATED INJURY TO A SUPERVISOR
  3. Supervisor completes “EMPLOYERS REPORT OF INDUSTRIAL INJURY” - Form A
  4. Employee completes “WORKERS COMPENSATION INJURY NOTICE” - Form B
  5. Supervisor completes “SUPERVISOR’S REPORT OF INJURY” - Form C
  6. Witness completes “WITNESS STATEMENT” – Form D
  7. Employee completes “AUTHORIZATION TO DISCLOSE, RELEASE AND USE PROTECTED HEATH INFORMATION – HIPAA” – Form E
  8. Employee completes “MEDICAL TREATMENT PROVIDER LIST” – Form F
  9. Click a folder below to download and fill out the proper forms.
  10. Supervisor to scan and email the below completed forms to: claims@7710insurance.com