Employer's Report of Injury
Please fill out the below information and click the submit button at the bottom of this page.
An insurance professional will contact you within 48 business hours regarding your claim.
 
EMPLOYEE (Required*)
Full Name (First Middle Last)*
Soc. Sec. #*  xxx-xx-xxxx
 Is employee an H2A worker?
*
Street  City* State Zip
Phone*Birth Date*   Marital Status   Dependents 
Occupation    Wage    Amount    Hire Date  
INJURY (Required*)
Date of Injury*Time of Injury (Hour/Min) :   Time Employee Began Work(Hour/Min) :   City/State/Zip Code Where Injury Occurred
What Kind of injury? (contusion, cut, fracture, sprain, strain, etc.)*   Body Part Injured*
How did injury occur?*
What object or substance directly harmed the employee? 
What was employee doing just before incident occured? 
Was there any witnesses? 
Witness Name     Phone # 
Last day worked                  Date Returned to work            Did Employee Die? 
If yes, what date? 
MEDICAL (Required*)
Was employee treated in an emergency room?
Was employee hospitalized overnight as an in-patient?  Case # from Hospital Log 
Did employee decline treatment? 
Physician/Clinic 
Address 
Phone  
Hospital 
EMPLOYER (Required*)
Full Business Name*  Fed ID#     Policy #* 
Mailing Address 
Accident Location*    Did accident occur on employer premises?* 
Address of Accident Location
(if different from mailing address)
 
Contact*    Title*    Phone*  Date injury was reported to employer* 
 
______________________________ 8/28/2016
Preparer's Signature (Employer) Date
 
 
Preparer's Name* Preparer's Title
 
 
Version 08292013:1135