Employee’s Report of Incident Employee's Report of Incident Step 1 of 4 25% 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*MaleFemaleUnknownMarital Status*Unmarried/Single/DivorcedMarriedSeparatedUnknownNumber of Dependents*Please list an Emergency Contact. First Last Phone Number Relationship to You Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Weekly (or Hourly) Wages HiddenDate 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 AM/PM Time Employee Reported for Work Day of Incident : Hours Minutes AM PM 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 detailList all witnesses to this incidentList 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* By submitting this form, you agree that you are signing this form electronically and that all information you provided to InSource Employer Solutions / Business Insurers of Georgia is complete and accurate to the best of your knowledge. You agree your electronic signature (hereafter referred to as "E-Signature") is the legal equivalent of your manual signature. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature. You acknowledge your understanding that any person who knowingly submits false or fraudulent information is guilty of a crime and may be subject to fines and/or confinement in state prison.Please Type Your Name* First Last Transcribed and/or translated by (if necessary) First Last Transcriber/Translator's Email Address HiddenFor Internal Use Only (Routing)HiddenMTWR-D HiddenF-D HiddenWKND-D HiddenHOL-D
