Preparer Information Preparer's Name Preparer's Phone Preparer's Title Preparer Is AgentCarrierAdminCarrier AdminCo-WorkerEmployerInjuredWorkerOther Date Prepared Preparer's Email
Employer Information Employer Name Address City State Zip Phone Fax Nature of Business Contact Person Contact Phone Contact Email
Employee Information First Name Last Name Address City State Zip Home Phone Cell Phone Social Security Date of Birth Age Gender MaleFemale Marital Status SingleMarriedDivorcedWidowed Total Dependents Occupation Department Date of Hire Employee Status Days Worked Per Week Time Shift Begins (Indicate AM/PM) Time Shift Ends (Indicate AM/PM) Wages DayWeekMonthYearOther If Wages Other, Units and Avg Units/Day: Date Injury Reported to Employer Has Employee Returned to Work? YesNo Date and Time of Return to Work Paid for the day of injury? YesNo Paid While Injured? YesNo
Accident Information Accident Date and Time Accident Location (address/department) Accident Description Work Process Employee Engaged In at Time of Accident Were Safeguards Provided? YesNo Were Safeguards Used? YesNo Was Accident on Premises? YesNo Date Worked Is this claim for reporting purposes only? YesNo Lost Time claim? YesNo Was the accident fatal? YesNo If Fatal, Date of Death Nature of Injury/Body Part Object/Substance Involved Name of Witness
Medical Provider Information Provider Name Address City State Zip Phone Initial Treatment NoneBy EmployerMinor Clinic/HospitalEmergency CareHospitalized > 24 HoursFuture Major Medical/Lost Time Anticipated Mode of Transportation Not ApplicableOwn CarOther VehicleAmbulanceMedEvacOther Did injury occur more than 3 days ago? YesNo If Yes, list reason for delay Is there a reason to place this claim under investigation? YesNo If Yes, list reason Comments