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Company Name:
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Reported By:
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Phone Number:
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Claim Contact:
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Email Address:
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Date of Injury:
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Reported to Fund Date:
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Reported to Company Date:
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First Name:
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Middle Name:
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Last Name:
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Employee Address Line 1:
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Employee Address Line 2:
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Employee City:
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Employee State:
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Employee Zip:
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Employee Phone:
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Employee Cell Phone:
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Employee Notes:
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Employee SSN:
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Employee Gender:
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Male
Female
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Employee DOB:
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Employee Occupation:
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Employee Hourly ROP:
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Employee Weekly ROP:
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Employee Class Code:
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Is Individual?
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EE
Sub-Contractor
Independent Contractor
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Employment Status
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Full Time
Part Time
Terminated
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If Terminated, What Date:
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Employee Language:
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English
Spanish
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Employee Hire State:
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Employee Hire Date:
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Date of Injury:
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Injury Time:
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Place of Accident / Last Exposure, Where:
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Co. Premises
Vehicle
Jobsite
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Place of Accident / Last Exposure, Address:
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Place of Accident / Last Exposure, City:
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Place of Accident / Last Exposure, State:
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Place of Accident / Last Exposure, Zip:
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Place of Accident / Last Exposure, Jurisdiction State:
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Was Employee Injured Out-of-State:
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Yes
No
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If Yes, Did Employee Sign Election of Jurisdiction Form:
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Yes
No
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Describe Accident:
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Witnesses Names:
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Result of Injury, Care Type:
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Admitted To Hospital
Emergency Room Only
Clinic
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Care Type Date:
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Hospital/Clinic Name:
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Hospital/Clinic Address:
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Hospital/Clinic City:
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Hospital/Clinic State:
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Hospital/Clinic Zip:
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Hospital/Clinic Phone Number:
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Has Employee Returned to Duty?
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Full Duty
Light
No
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If Employee Has Returned to Duty, What Date:
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Is Further Medical Aid Needed?
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Yes
No
Unknown
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Needs Authorization
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Yes
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Needs Authorization For:
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Name or Facility for which Authorization is Required:
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Name or Facility Phone:
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Does Your Company Have a Drug Policy?
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Yes
No
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Was Employee Post Accident Drug Tested/
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Yes
No
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Notes:
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Completed By:
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