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HCSP Estimate Request

Health Care Savings Plan (HCSP) Estimate
Name

First Name
Last Name
Employee Number
Department
Phone
Area CodePhone Number
Email
Have you had lost time from a Work Comp Injury during your employment here?

Yes
No

Which describes your Work Comp Claim (Choose all that apply)

I missed less than 3 days of work

I only missed work for Dr. appts

I supplemented my work comp pay with sick leave

I have had just one work comp claim with lost time

I have had multiple work comp claims with lost time

Time of Year and/or approximate dates of lost time (decades/years/months/dates, anything you can remember)
Anything else you can provide that may help us locate your work comp claim records?

Captcha
After you click the Submit button above, watch your work email for your HCSP estimate. We attempt to turn these requests around within 24 hours. Please call 218.726.2422 if you do not get a reply within 24 hours.
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