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Employer
Employer
Claimant
Claimant
Employment
Employment
Injury
Injury
Submitter
Submitter

Insurance ID #:*

Invalid value

Employer Name:*

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:*

Phone Number:

Email:

Invalid value

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Hire Date:*

Job Title:*

Department (NAICS Code):*

Number of Days Worked per Week (Or Shift Work):*

Probationary?:*

Yes

Wage Rate at Time of Injury:*

per Hour

per Day

per Week

per Month

Normally Scheduled Days Off:

Returned to Work Date:

Returned at What Wage (per week):

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Date of Injury:*

Time of Injury:*

Location of Injury/Accident:*

County of Injury:*

Date Injury Reported to Employer:*

1st Day of Work Missed:

Did Employee Receive Full Pay on Date of Injury?:

Yes

Did Injury Occur on Employer Premises?:

Yes

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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Submitter's Name:*

Submitter's Phone Number (for follow-up questions):*

Submitter's Email Address (for receipt confirmation):*

Is this an Emergency?:

Yes

Additional Comments:

Supporting Documents:

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Errors Summary:

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