Agent Resource Center Agency Link Account Loss Runs About Financial Information Answers To Your FAQs Become An Agent Find an Agent Fraud Resource Center Helpful Links Company Holiday Schedule Claims Management Claims Kit Report an Injury Online Safety Training Safety Training Video List Register for Video Access Login to Safety Training We've improved our First Report Of Injury online form! Instantly receive your claim number after submitting the form. Use any browser - Internet Explorer, Chrome, Safari, Edge, Firefox or your mobile device. Report an Injury * yellow fields are required Step 1 of 7 14% Date of Injury (mm/dd/yyyy)* MM slash DD slash YYYY Your Email* Recipient #1 Recipient #2 Recipient #3 Recipient #4 Recipient #5 Social Security #* Employee Name* First Last Date of Birth (mm/dd/yyyy)* MM slash DD slash YYYY Address* Street Address City State / ProvinceAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Code County Phone*ExtensionGender*SelectMaleFemaleMarital StatusSelectDivorcedMarriedSingleWidowedSeparatedUnknownNumber of DependentsPlease enter a number from 0 to 9999.Occupation*SelectACCT - Accountant/AuditorAIDE - Aide/AssistantBUSP - Business ProfessionalCARP - CarpenterCLER - ClerkCOMP - Computer SpecialistCOUN - CounselorCREW - CrewCUST - Custodial WorkerDRIV -DriverELEC - ElectricianENG - EngineerFSW - Food Service WorkerGROU - Grounds CrewHCW - Healthcare WorkerINST - InstructorLAB - LaborerLAND - LandscaperMACH - MachinistMAIN - Maintenance WorkerMANG - ManagementMECH - MechanicOFFA - Office/Administrative Support WorkerOPER - OperatorPLUM - PlumberPSW - Protective Service WorkersSALE - Sales WorkerTEAC - TeacherTECH - TechnicianTRUD - Truck DriverWELD - Welder Employment StatusSelectFull TimePart TimeSeasonal Full TimeSeasonal Part TimeTemporary Full TimeTemporary Part TimeEmployer* Policy Number Employer Address* Street Address City State / ProvinceAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Code Employer Phone*ExtensionCounty Contact* First Last Contact Phone*ExtensionContact Fax numberContact Email* Did injury or illness occur on employer's premises?*SelectYesNoState of injury*SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificAddress where injury occurred if different than above? Street Address City State / ProvinceAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Code Time employee began work (HH:MM)* : Hours Minutes AM PM AM/PM Time of occurrence (HH:MM)* : Hours Minutes AM PM AM/PM Last Date WorkedMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Full pay for day of injuryYesNoDate Disability BeganMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date Employer Notified*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date Returned to Work (if applicable)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of Hire*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Type of Injury*Select01 - No Physical Injury02 - Amputation03 - Angina Pectoris04 - Burn07 - Concussion10 - Contusion13 - Crushing16 - Dislocation19 - Electric Shock22 - Enucleation (To Remove, Ex: Tumor , Eye, Ect)25 - Foreign Body28 - Fracture30 - Freezing31 - Hearing Loss or Impariment Traumatic32 - Heat Prostration34 - Hernia36 - Infection37 - Inflammation38 - Adverse reaction to a vaccination or inoculation40 - Laceration41 - Myocardial Infraction (Heart Attack)42 - Poisoning - General (Not OD or Cumulative Injury)43 - Puncture46 - Rupture47 - Severance49 - Sprain52 - Strain53 - Syncope54 - Asphysiation55 - Vascular58 - Vision Loss59 - All Other Specific Injuries, NOC60 - Dust Disease, NOC (All Other Pneumoconiosis)61 - Asbestosis62 - Black Lung63 - Byssinosis64 - Silicosis65 - Respiratory Disorders (Gasses, Fumes, Chemicals, Etc)66 - Poisoning - Chemical (Other Than Metals)67 - Poisoning - Metal68 - Dermatitis69 - Mental Disorder70 - Radiation71 - All Other Occupational Disease Injury, NOC72 - Loss of Hearing73 - Contagious Disease74 - Cancer75 - AIDS76 - VDT - Related Disease77 - Mental Stress78 - Carpal Tunnel Syndrome79 - Hepatitis C80 - All Other Cumulative Injuries, NOC82 - Absorption, Ingestion or Inhalation, NOC- Not otherwise classified in any other code. Applies only to non-impact cases in which the injury resulted from inhalation, absorption (skin contact), ingestion of harmful substances, or vaccinations.83 - COVID 1990 - Multiple Physical Injuries Only91 - Multiple Injuries Including both Physical & PsychologicalPart of Body Affected*Select61 - Abdomen Including Groin55 - Ankle64 - Artifical Appliance43 - Back - Disc47 - Back - Spinal Cord91 - Body Systems & Multiple Body Systems12 - Brain62 - Buttocks44 - Chest Including Ribs, Sternum & Soft Tissue13 - Ear(s)32 - Elbow14 - Eye(s)19 - Facial Bones36 - Finger(s)56 - Foot58 - Great Toe35 - Hand(s)18 - Head - Soft Tissue49 - Heart51 - Hip48 - Internal Organs53 - Knee24 - Larynx42 - Low Back Area Including Lumbar & Lumbo-Sacral33 - Lower Arm54 - Lower Leg63 - Lumbar &/or Sacral Vertebrae(Veretbrae NOC Trunk)60 - Lungs17 - Mouth90 - Multiple Body Parts10 - Multiple Head Injury50 - Multiple Lower Extremities40 - Multiple Trunk30 - Multiple Upper Extremities22 - Neck - Disc20 - Neck - Multiple Injury25 - Neck - Soft Tissue23 - Neck - Spinal Cord66 - No Physical Injury15 - Nose46 - Pelvis45 - Sacrum & Coccyx38 - Shoulder(s)11 - Skull16 - Teeth26 - Thachea37 - Thumb57 - Toe(s)31 - Upper Arm Including Clavicle & Scapular41 - Upper Back Area (Thoracic Area)42 - Upper Leg21 - Vertebrae99 - Whole Body34 - Wrist39 - Wrist(s) & Hand(s)Cause of Injury*Select01 - Burn - Acid Chemicals02 - Burn - Contact with Object03 - Burn - Temperature Extremes04 - Burn - Fire or Flame05 - Burn - Steam or Hot Fluids06 - Burn - Dust, Gasses, Fumes, Vapor07 - Burn - Welding Operations08 - Burn - Radiation09 - Burn - Miscellaneous10 - Caught In - Machinery11 - Burn - Cold Objects or Substances12 - Caught In - Object Handled13 - Caught In or Between - Miscellaneous14 - Burn - Abnormal Air Pressure15 - Cut, Injured By - Broken Glass16 - Cut, Injured By - Hand Tool Use17 - Cut, Injured By - Object Being Lifted or Handled18 - Cut, Injured By - Power Tool19 - Cut, Injured By - Miscellaneous20 - Caught In - Collapsing Material (Slides of Earth)25 - Fall or Slip - From Different Level26 - Fall or Slip - From Ladder27 - Fall or Slip - From Liquid28 - Fall or Slip - Into Openings29 - Fall or Slip - Same Level30 - Slipped - Did Not Fall31 - Fall or Slip - Fall, Slip, Trip, NOC32 - Fall or Slip - On Ice or Snow33 - Fall or Slip - On Stairs40 - Motor Vehicle - Crash of Water Vehicle41 - Motor Vehicle - Crash of Rail Vehicle45 - Motor Vehicle - Collision or Sideswipe with Another Vehicle46 - Motor Vehicle - Collision with a Fixed Object47 - Motor Vehicle - Crash of Airplane48 - Motor Vehicle - Vehicle Upset50 - Motor Vehicle - Miscellaneous52 - Strain Injury by - Continual Noise53 - Strain Injury by - Twisting54 - Strain Injury by - Jumping55 - Strain Injury by - Holding or Carrying56 - Strain Injury by - Lifting57 - Strain Injury by - Pushing or Pulling58 - Strain Injury by - Reaching59 - Strain Injury by - Using Tool or Machinery60 - Strain Injury by - Miscellaneous61 - Strain Injury by - Wielding or Throwing65 - Stepping on/Striking - Moving Parts of Machine66 - Stepping on/Striking - Object Being Lifted or Handled67 - Stepping on/Striking - Sanding, Scraping, Cleaning Operations68 - Stepping on/Striking - Stationary Object69 - Stepping on/Striking - Sharp Object70 - Stepping on/Striking - Miscellaneous74 - Struck/Injured by - Fellow Worker, Patient75 - Struck/Injured by - Falling or Flying Object76 - Struck/Injured by - Hand Tool or Machine in Use77 - Struck/Injured by - Motor Vehicle78 - Struck/Injured by - Moving Part of Machine79 - Struck/Injured by - Object Being Lifted or Handled80 - Struck/Injured by - Object Handled by Others81 - Struck/Injured by - Miscellaneous82 - Miscellaneous - Absorption, Ingestion or Inhalation, NOC83 - Pandemic84 - Burn - Electrical Current85 - Struck/Injured by - Animal or Insect86 - Struck/Injured by - Explosion or Flare Back87 - Miscellaneous - Foreign Matter (Body) in Eye(s)89 - Miscellaneous - Person in Act of Crime90 - Miscellaneous - Other Than Physical Cause of Injury94 - Rubbed/Abraded by - Repetitive Motion95 - Rubbed/Abraded by - Miscellaneous97 - Strain Injury by - Repetitive Motion98 - Miscellaneous - Cumulative, NOC99 - Miscellaneous - Other Miscellaneous, NOCWere safeguards or safety equipment provided?*SelectYesNoWere safeguards or safety equipment used?*SelectYesNoAll equipment, materials, or chemicals employee was using when accident or illness exposure startedHow injury or illness/abnormal health condition occurred. Describe the sequence of events and include any objects or substances directly responsible*If fatal, give date of deathMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Witness Name First Last Witness Phone NumberExtensionInitial Treatment No Medical Treatment/Minor by Employee Health Care Provider Panel Physician Employee Physician Physician First Name or Health Care Provider First Last Physician Address Street Address City State / ProvinceAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Code Person Completing This Form* First Last Title* Phone*Extension Please review your claim before submission.Using the buttons at the bottom of the page, first PRINT this page for your records. Then press SUBMIT to enter your claim and receive your claim number!{all_fields:exclude[7,67]}