Report An InjuryPreparer InformationSome description about this sectionFirst NameLast NamePreparer's PhonePreparer's TitleDate PreparedPreparer's EmailIs this claim for reporting purposes only? Yes NoDid injury occur more than 3 days ago? Yes NoEmployer InformationEmployer NameAddressAddress Line 1CityStateZip CodePhoneEmployee InformationFirst NameLast NameAddressAddress Line 1CityStateZip CodeHome PhoneCell PhoneSocial SecurityDate of BirthAgeGender- Select -MaleFemaleMarital Status- Select -SingleMarriedDivorcedWidowedTotal DependentsOccupationDepartmentDate of HireEmployee Status- Select -Piece WorkerVolunteerSeasonalApprentice - IFull-TimePart-TimeNot EmployedRetiredOn-StrikeDisabledOtherDays Worked Per WeekTime Shift Begins (Indicate AM/PM)Time Shift Ends (Indicate AM/PM)WagesDate Injury Reported to EmployerHas it been more than 14 days since the accident occurred? Yes NoList reason for delayHas Employee Returned to Work? Yes NoDate and Time of Return to WorkPaid While Injured? Yes NoPaid for the day of injury? Yes NoAccident InformationAccident DateAccident TimeAccident Location (address/department)Accident DescriptionWork Process Employee Engaged In at Time of AccidentWere Safeguards Provided? Yes NoWere Safeguards Used? Yes NoWas Accident on Premises? Yes NoDate Last WorkedWas the accident fatal? Yes NoDate of fatalityNature of Injury/Body PartObject/Substance InvolvedName of WitnessesMedical Provider InformationProvider NameAddressAddress Line 1CityStateZip CodePhoneCommentsSubmit Form
