Policy Number or Self-Insured
Number:
Check if Self-Insured
Policy Period From:
Policy Period To:
Claims Administrator: (Name, Address &
Phone Number)
INJURED EMPLOYEE/WAGE INFORMATION
Injured Employee's Legal Name
First*:
Middle:
Last*:
Employee's Occupation/Job Title*:
Date of Birth*:
Social Security Number*:
Date Hired*:
Street1*:
Street2:
City*
,
State
Zip
Phone*:
Sex :
Marital Status:
Employment Status *:
Number of Dependents:
Wage Rate*:
per
How many days does the employee work per week:
Hours worked per Day:
Does the employee get full pay for Date of Injury?
Did the employee's salary continue after the injury?
Occurrence Information
Time Employee Began Work:
Date of injury/illness*:
Time Injury Occurred:
Last Work Date:
Date Employer Notified:
Employer Contact Name:
Contact Phone Number:
Type of Injury/Illness*:
Part of Body Affected*:
Did Injury/Illness occur on Employer's Premises?
Department or location where accident or illness exposure occurred:
All Equipment, Materials, or Chemicals Employee was using when accident or
illness exposure occurred:
Specific Activity the Employee was engaged in when the accident or illness
exposure occurred.
Work Process the Employee Was Engaged in when accident or illness exposure
occurred.
How injury or illness/abnormal health condition occurred. Describe the sequence
of events and include any objects
or substances that directly injured the employee or made the employee ill.
Date Returned to Work:
If Fatal, Date of Death:
Were Safeguards or Safety Equipment Provided?
Were they used?
Physician/Health Care Provider (Name & Address)
Hospital
(Name & Address)
Initial Treatment
Witness to Accident (Name & Phone Number)
Date Administrator Notified*:
Date Prepared*:
Preparer’s Name/Title*:
Preparer’s Phone Number*:
To receive and email confirmation of this document, please
enter your email address: