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)
Date Of Birth: (MM/DD/YYYY)
Tax Filing Status:
Single, Head Of Household
Married, Filing Joint
Married, Filing Separate
II. EMPLOYER DATA
III. INJURY/MEDICAL DATA
Last Day Worked:
Date Employee Returned To Work:
Did Employee Die?:
Date Of Death:
Injury occur on premises?:
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?
Was employee hospitalized overnight as in-patient?
If treatment was given away from the worksite, where was it given? (name, address, city, state, zip of facility)
IV. OCCUPATION AND WAGE DATA
Total gross weekly wage (highest 39 of 52)
Number of weeks used
Value of discontinued fringes
Occupation (Be Specific)
Was Employee a volunteer worker?
Was Employee certified as vocationally handicapped?
Date employer notified by employee
V. PREPARER DATA
Email Verification To (email address)