First Report of Injury

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?

Yes

No

*

Male

Female

Street

City* State

Zip

Phone*

Birth Date* Marital Status Dependents

Occupation

Wage Amount
Hire Date Hire State

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 occurred?

Was there any witnesses?

Yes

No

Witness Name Phone #

Last day worked No Time Lost Date Returned to work Did Employee Die?

Yes

No

If yes, what date?

MEDICAL (Required*)

Was employee treated in an emergency room?

Yes

No

Was employee hospitalized overnight as an in-patient?

Yes

No

Case # from Hospital Log

Did employee decline treatment?

Yes

No

Physician/Clinic

Address

Phone

Hospital

EMPLOYER (Required*)

Full Business Name*

Fed ID# Policy #*

Mailing Address

Accident Location* Did accident occur on employer premises?*

Yes

No

Address of Accident Location
(if different from mailing address)

Contact* Title* Phone*

Date injury was reported to employer*

______________________________

______________________________Reporting Only Claim

Preparer's Signature (Employer)

Date

Preparer's Name*

Preparer's Title

Do you want a claim number emailed to you?

Yes

No

If yes, what email address should we send it to?