Employee’s Report of Incident

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*

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*

Date of Incident*

Date Employee Reported Incident*

Time of Incident

:

Time Employee Reported for Work Day of Incident

:

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)

Please Type Your Name*

First Last

Transcribed and/or translated by (if necessary)

First Last

Transcriber/Translator's Email Address

Employee's Report of Incident