Report an Injury | Lackawanna Insurance Group

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Report an Injury

* yellow fields are required

Step 1 of 7

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Date of Injury (mm/dd/yyyy)*
Date Format: 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)*
Date Format: MM slash DD slash YYYY
Address*
Street Address City State Zip Code
County
Phone*
Extension
Gender*
Marital Status
Number of Dependents
Please enter a number from 0 to 9999.
Occupation*

Employment Status
Employer*
Policy Number
Employer Address*
Street Address City State Zip Code
Employer Phone*
Extension
County
Contact*
First Last
Contact Phone*
Extension
Contact Fax number
Contact Email*

Did injury or illness occur on employer's premises?*
State of injury*
Address where injury occurred if different than above?
Street Address City State Zip Code
Time employee began work (HH:MM)*

: HH

MM
Time of occurrence (HH:MM)*

: HH

MM
Last Date Worked
Full pay for day of injury
Date Disability Began
Date Employer Notified*
Date Returned to Work (if applicable)
Date of Hire*

Type of Injury*
Part of Body Affected*
Cause of Injury*
Were safeguards or safety equipment provided?*
Were safeguards or safety equipment used?*
All equipment, materials, or chemicals employee was using when accident or illness exposure started
How 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 death

Witness Name
First Last
Witness Phone Number
Extension
Initial 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 Zip Code
Person Completing This Form*
First Last
Title*
Phone*
Extension

Thank you for your submission. You are not done yet!
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!
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