Employee’s Report of Incident

Employee's Report of Incident

Step 1 of 4

Have you reported this incident directly to your employer?*
- Yes
- No
You may continue with this online submission; however, you must report this incident directly to your employer as soon as possible. Failure to follow your employer’s workplace injury reporting procedures may cause a delay in processing your claim.
Please continue on to the next page. As a reminder, failure to follow your employer’s workplace injury reporting procedures may cause a delay in processing your claim.

Company Employing Injured Worker*
Injured Worker's Email Address (or Supervisor's Email Address)*
Name of Injured Worker*
First Last
Primary Phone Number*
Is the primary phone number a mobile or landline?*
- Mobile
- Landline
Secondary Phone Number
Is the secondary phone number a mobile or landline?
- Mobile
- Landline
Social Security Number*
Injured Worker's Birthdate*
MM slash DD slash YYYY
Sex of Injured Worker*
Marital Status*
Number of Dependents*
Please list an Emergency Contact.
First Last Phone Number Relationship to You
Home Address*
Street Address Address Line 2 City State ZIP Code
Weekly (or Hourly) Wages
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Date of This Report*
MM slash DD slash YYYY

Date of Incident*
MM slash DD slash YYYY
Date Employee Reported Incident*
MM slash DD slash YYYY
Time of Incident

: Hours

Minutes

AM/PM
Time Employee Reported for Work Day of Incident

: Hours

Minutes

AM/PM
Person Employee Reported Incident To*
First Last
Client Where Incident Occurred (For staffing companies only)
Address Where Incident Occurred*
Street Address Address Line 2 City State ZIP Code

Describe the incident in detail (how, why, where, what)*
Type of Injury (cut, sprain, bruise, fracture, etc.)*
Which part of body injured (be specific)*
Are there any safety issues that contributed to this injury? Please detail
List all witnesses to this incident
List all prior injuries sustained at work and outside of work in the last 10 years that required medical attention (include dates, injuries, and body parts)
Consent*
I, employee, the undersigned, certify that the above is a true and correct statement of fact and that I made such statements of my own free will. I understand that any payments to me or anyone else for expenses in connection with my accident and resulting injury is not an admission of liability on the part of my employer and/or the Insurance Company. I authorize full access to copies of medical records, radiology reports, drug/alcohol screenings, and documents of any kind relating to my past or present injury/illness to my employer. I hereby agree to release this information and hold all such medical providers harmless for the release of this information as set forth in this authorization. “Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
Please Type Your Name*
First Last
Transcribed and/or translated by (if necessary)
First Last
Transcriber/Translator's Email Address
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For Internal Use Only (Routing)
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MTWR-D
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F-D
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WKND-D
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HOL-D

Employee's Report of Incident

Step 1 of 4

For Internal Use Only (Routing)