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   *Gender
*Street Address *Zip    CIty   State
*Date Hired        *Date of Injury *Occupation *Birthdate
*Marital Status 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? 
*How did injury occur? Did Employee Die?  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?  Overnight Hospitalization? 
Where treatment given, Name & Address
PREPARER
*Preparer Name *Telephone Number Email to send verification