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Employer
Employer
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Claimant
Employment
Employment
Injury
Injury
Submitter
Submitter
Insurance ID #:
*
Invalid value
Employer Name:
*
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Nature of Business:
*
Address:
*
Address 2:
City:
*
State:
*
Zip:
*
Employee Supervisor's Name:
*
Employee Supervisor's Phone Number:
*
Employee Supervisor's Email:
*
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Employee First Name:
*
Employee Last Name:
*
Middle Initial:
SSN:
*
Address:
*
Address 2:
City:
*
State:
*
Zip:
*
Gender:
*
Male
Female
Birthday:
*
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Phone Number:
Email:
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Hire Date:
*
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Job Title:
*
Department (NAICS Code):
*
Number of Days Worked per Week (Or Shift Work):
*
Probationary?:
*
Yes
No
Wage Rate at Time of Injury:
*
per Hour
per Day
per Week
per Month
Normally Scheduled Days Off:
Returned to Work Date:
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October, 2024
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Returned at What Wage (per week):
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Date of Injury:
*
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Time of Injury:
*
AM
PM
Location of Injury/Accident:
*
County of Injury:
*
Date Injury Reported to Employer:
*
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1st Day of Work Missed:
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October, 2024
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Did Employee Receive Full Pay on Date of Injury?:
Yes
No
Did Injury Occur on Employer Premises?:
Yes
No
Type of Injury/Illness (i.e, contusion, strain, fracture):
*
Body Part Affected (i.e, left upper arm, right lower leg, left hip, right eye, low back):
*
How Injury Occurred ( i.e. fell down step, twisted ankle on curb):
*
Treating Physician - Name and Address (Optional):
Initial Treatment Given (Optional):
No Initial Treatment
Minor: By Employer
Minor: Clinical/Hospital
Emergency Room
Hospitalized > 24 hrs
Hospital/Treating Facility - Name and Address (Optional):
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Date of Death (If Fatal Injury):
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October, 2024
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Previous
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Submitter's Name:
*
Submitter's Phone Number (for follow-up questions):
*
Submitter's Email Address (for receipt confirmation):
*
Is this an Emergency?:
Yes
No
Additional Comments:
(None)
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