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Employer
Employer Name
Address
Phone Number
Fax Number
Policy Number
Contact Name
Contact Email
Contact Phone
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Indicates a required field
Employee
Employee Name
Last Name
First Name
Middle Initial
Address
Phone Number
Date of Birth
Gender
Male
Female
Race/Ethnicity
Asian/Pacific Islander
Black
Hispanic
American Indian / Alaskan Native
White
Other
Race/Ethnic Identification
Social Security Number
Job Title
Date of Hire
Department
W2 Employee of Employer
Yes
No
Please explain relationship
Injury Information
Date of Injury
Time of Injury
Date Injury Reported
Location of Injury
Primary Business
Off Site
During Travel
Accident Description
Emergency Room Treatment
Yes
No
Hospitalized Overnight
Yes
No
Medical Attention Away from Worksite
Yes
No
Physician/Medical Facility Name
Physician/Medical Facility Phone Number
Losing Time from Work
Yes
No
Lost Time Beginning Date
Time Employee Began Work
Hours per Week
Rate of Pay
Wage Basis
Hourly
Daily
Weekly
Biweekly
Semimonthly
Monthly
Quarterly
Annually
Speaks English
Yes
No
Preferred Language
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