Report An Injury

Name of Person Filing Claim(Required)

First Middle Initial Last

Phone(Required)

Email(Required)

Employer Information

Employer Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP / Postal Code

Supervisor Name(Required)

First Last

Supervisor Phone #(Required)

Insureds Policy Number

Payroll Class Code

Did Employee Receive full Pay on Date of Injury?

Yes

Employee Information

Employee Name(Required)

First Middle Initial Last

Employee's Current Mailing Address(Required)

Street Address Address Line 2 City State ZIP / Postal Code

Phone(Required)

Gender(Required)

Date of Birth(Required)

Marital Status

Job Title(Required)

Hire Date(Required)

Employment Status(Required)

Part-Time

Full-Time

Hours and days worked per week(Required)

Regular Days Off(Required)

Is employee owner/officer or partner?(Required)

County of Injury

Did the employee return to work?(Required)

If yes, what date did they return to work?

Accident Information

Accident Date(Required)

Accident Location Address(Required)

Street Address Address Line 2 City State ZIP / Postal Code

Accident Description(Required)

Date Reported to Employer(Required)

# of Employees Injured(Required)

Fatal Injury

Nature of Injury (Body Part)(Required)

Witness Information

Witness Name

First Last

Address

Street Address Address Line 2 City State ZIP / Postal Code

Phone

Hospital Information

Hospital Name

Street Address

Street Address Address Line 2 City State ZIP / Postal Code

Additional Comments/Concerns

Report An Injury

Employer Information

Employee Information

Accident Information

Witness Information

Hospital Information

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