Instructions: Fill in all data fields on the form and press Submit at the bottom of page.
** All forms submitted after 10:00 am EST will not be processed until the next business day.
** Please notify us via phone immediately if the injury is severe and can not wait until the next business day.
Blue fields are required.
I. EMPLOYEE DATA
Soc Sec Num: Date Of Injury: (MM/DD/YYYY) Employee Name: (Last, First, MI)
Address: (Number and Street) City: State: Zip:
Date Of Birth: (MM/DD/YYYY) Sex: M F Dependents: Phone:
Tax Filing Status: Single Single, Head Of Household Married, Filing Joint Married, Filing Separate
II. EMPLOYER DATA
Employer Name: Federal ID:
Employer Address: City: State: Zip:
III. INJURY/MEDICAL DATA
Last Day Worked: Date Employee Returned To Work: Did Employee Die?: Yes No Date Of Death:
Injury City: Injury State: Injury County: Injury occur on premises?: Yes No
Case Number OSHA/MIOSHA log: Time employee began work Time of event
What was the employee doing just before the incident? Describe the activity, tools, equipment, or material the employee was using.
How did the injury occur? Examples: "When ladder slipped on wet floor, worker fell 20 feet"; "Worker was sprayed with chlorine"
Describe the nature of injury or illness Part of body directly effected by the injury or illness
What object or substance directly harmed the employee? Examples: concrete floor, chlorine, radial arm saw. blank if does not apply
Physician or health care professional: Was employee treated in emergency room? Yes No Was employee hospitalized overnight as in-patient? Yes No
If treatment was given away from the worksite, where was it given? (name, address, city, state, zip of facility)
IV. OCCUPATION AND WAGE DATA
Date Hired: Total gross weekly wage (highest 39 of 52) Number of weeks used Value of discontinued fringes
Occupation (Be Specific) Was Employee a volunteer worker? Yes No Was Employee certified as vocationally handicapped? Yes No
Date employer notified by employee
V. PREPARER DATA
Preparer's Name Telephone Number Date Prepared
Email Verification To (email address)