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Report An Injury

If you have any issues submitting a claim for please call us 678-766-8242 x214

Name of Person Filing Claim(Required)

Employer Information

Address(Required)
Supervisor Name(Required)
Did Employee Receive full Pay on Date of Injury?

Employee Information

Employee Name(Required)
Employee's Current Mailing Address(Required)
Date of Birth(Required)
Hire Date(Required)
Employment Status(Required)
Is employee owner/officer or partner?(Required)
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)
Date Reported to Employer(Required)
Fatal Injury

Witness Information

Witness Name
Address

Hospital Information

Address

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