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Workers’ Compensation ADR Program Assistance

Contact the Office of the Ombudsman

Use this page to contact the Office of the Ombudsman about an existing workers’ compensation ADR Program, claim, ADR case, Program form or request for participant assistance.

The Ombudsman provides information about the applicable ADR process, helps participants identify the appropriate Program procedure or contact, assists communication, reviews questions and concerns impartially, and may help participants explore informal resolution. The Ombudsman does not represent any party and does not provide legal advice.

Is this the right form?

This form is for injured workers, claims administrators, employers, medical providers, attorneys, union or labor-management representatives, and other participants who have a question or concern involving an existing workers’ compensation ADR Program.

Do not use this form for sales messages, vendor solicitations, media requests, employment inquiries, general corporate matters or inquiries about creating a new ADR Program.

Messages outside the Ombudsman’s participant-assistance function may not receive a response through this form.

Send an Ombudsman inquiry

Provide enough information to help the Office of the Ombudsman identify the applicable ADR Program and understand your question or concern. Fields marked with an asterisk are required. Leave optional fields blank when the information is unknown or unavailable.

Important submission notice: Unless the governing Program instructions expressly state otherwise, submitting this form does not file a workers’ compensation claim, appeal, grievance, request for mediation, arbitration demand or other time-sensitive document, and it does not extend any deadline.

Protect sensitive information: Do not include Social Security numbers, financial-account information, full dates of birth, complete medical records or other highly sensitive information.

About you

Tell us who you are, your role in the matter, and how the Ombudsman may contact you.

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Program and claim information

Enter the information you know. You may leave an optional field blank when the information is not known or does not apply.

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Please enter the date of injury in mm/dd/yyyy format.
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Your inquiry

Select the topic that most closely matches your question. In the message, briefly describe what happened, what information or response may be missing, and what assistance you are requesting from the Ombudsman.

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File uploads: Attach only documents reasonably necessary to identify or explain the inquiry. Do not upload complete medical files, Social Security numbers, financial information or other highly sensitive material.

PDF is preferred. You may upload up to three files, with a maximum size of 10 MB per file. JPG, JPEG and PNG screenshots are also accepted. DOCX documents may be submitted when a PDF is not available.

When practical, combine related pages into one PDF. Do not upload password-protected or encrypted files.

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Review and send

Confirm that your contact information is correct, review the applicable website policies, and complete the verification before sending the inquiry.

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You must agree to the Terms of Use before sending this inquiry.
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After you send the form

The Ombudsman will review the information to identify the applicable ADR Program and the appropriate next step. Depending on the inquiry, the Ombudsman may request clarification or communicate with appropriate Program participants.

Important notice: The Office of the Ombudsman is not a law firm and does not provide legal representation. Contacting the Ombudsman does not create an attorney-client relationship and does not itself file a claim, appeal, grievance, arbitration request or other time-sensitive document.

Review the Privacy Policy for information concerning the use of information submitted through this website.

Before you send

  • Confirm that your question involves an existing workers’ compensation ADR Program.
  • Identify the ADR Program, union or employer when known. If you are unsure which Program applies, you may still submit the form.
  • Do not include unnecessary sensitive personal information.
  • Do not use this form to file a time-sensitive document.

 

Helpful information

When available, having the following information may help the Ombudsman identify your matter:

  • ADR Program, insurer, union and employer
  • Insurance claim number
  • Date of injury

You do not need to know every item before submitting an inquiry.

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