Employee’s Report of Incident

Step 1 of 3

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 / Province / Region ZIP / Postal Code Country
Weekly (or Hourly) Wages
Hidden
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
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 / Province / Region ZIP / Postal Code Country

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*
By submitting this form i agree to the below:
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
Hidden
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

Step 1 of 3

For Internal Use Only (Routing)