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Report an Injury

* yellow fields are required

Step 1 of 7

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 Zip Code
County
Phone*
Extension
Gender*
Marital Status
Number of Dependents
Please enter a number from 0 to 9999.
Occupation*

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)*

: Hours

Minutes

AM/PM
Time of occurrence (HH:MM)*

: Hours

Minutes

AM/PM
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