First Report of Injury
Instructions:
** All forms submitted after 10:00 am EST will be processed the next business day.
** Please notify us by phone immediately if the injury is severe and unable to wait until the next business day.
EMPLOYEE INFORMATION
*
Full Name
*
Soc Sec #
xxx-xx-xxxx
SSN required, format xxx-xx-xxxx
*
Gender
Male
Female
*
Street Address
*
Zip
CIty
State
*
Date Hired
*
Date of Injury
*
Occupation
*
Birthdate
*
Marital Status
Single
Single, Head of Household
Married, Filing Jointly
Married, Filing Separate
Dependants
*
Phone No.
xxx-xxx-xxxx
EMPLOYER INFORMATION
*
Employer Name
Federal ID
*
Employer Street
*
Zip
City
State
Contact Person
Title
INJURY INFORMATION
*
Injury Reported on
*
Last Day Worked
Date Returned To Work
*
Injury City
*
Injury State
Injury County
Injury occured on premises?
Yes
No
*
How did injury occur?
Did Employee Die?
Yes
No
If yes, what date?
*
What Kind of injury?
*
Body Part Injured
What was employee doing just before incident occurred?
What object or substance directly harmed the employee?
MEDICAL INFORMATION
Physician/Healtcare Worker
Emergency Room treatment?
Yes
No
Overnight Hospitalization?
Yes
No
Where treatment given, Name & Address
PREPARER
*
Preparer Name
*
Telephone Number
Email Address