I have explained the details of this incident to my supervisor, but do not wish to seek any outside medical treatment this time.

I understand that by signing this statement, I am not giving up my right to seek medical treatment in the future, if I feel it is necessary. I further understand that if I do not follow the procedures as reflected in my employment agreement, my injury may not be covered by Workers’ Compensation.

I understand that a drug screen may be required upon report of an injury, and by not complying, I may not be covered by Workers’ Compensation for this injury.

By submitting this form, I agree that I am signing this form electronically and that all information I provided to InSource Employer Solutions / Business Insurers of Georgia is complete and accurate to the best of my knowledge. I agree my electronic signature (hereafter referred to as "E-Signature") is the legal equivalent of my manual signature. I also agree that no certification authority or other third party verification is necessary to validate my E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of my E-Signature. I acknowledge my 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.