Worker's Compensation Online Submission Form

Connect with the Haisha Insurance Worker’s Comp team by experiencing our new online submission tool.

The below tool replaces the need for the Acord 130 application. Once this form is completed and submitted, your assigned Workers' Compensation Account Executive will immediately be notified.

We will review your request and contact you if any additional information is needed. If the form is complete we will begin the submission process and provide confirmation within 24 hours.