Employer’s Report of Incident

Are you reporting a Catastrophic (CAT) Claim?
A Catastrophic (CAT) Claim is defined as the injured worker having one or more of the following conditions:
- 1. Loss of Life
- 2. Formal Admission into a hospital for treatment. (This does not include emergency room only visits or treatment).
- 3. Loss of an Eye
- 4. Amputation - Full or partial amputation of a limb or other external body part. This includes fingertip amputations with or without bone loss; medical amputations resulting from irreparable damage; and amputations of body parts that have since been reattached.
If you are reporting a CAT claim, call your account manager immediately before completing this form.
Based on the definition above, will your Report of Incident classify as a Catastrophic (CAT) Claim?*
- Yes
- No
Have you called your InSource Account Manager to notify them of this incident?*
- Yes, I called my account manager to notify them of this incident.
- No, I did not call my account manager to notify them of this incident.
Please call your InSource Account Manager before proceeding with this entry.

Are you reporting a Catastrophic (CAT) Claim?