Worker's Compensation Report Please enter the information requested below. All fields are required unless otherwise noted. If you would like a printable form that you can mail or fax to us, please choose a version to download: English  Spanish Name of Person Completing Report Email Address Verify Email Address Company Name Address City, State, (Zip) State of Employment Date of Accident Employer Contact Name and Phone Number Time of Accident, AM or PM Employee / Injured Information Name Address City State Zip Phone 1 Phone 2 (Optional) Birthdate Age Social Security Number Check all that apply: Male Female Single Married Divorced Widowed Full Time Part Time Commission Salaried Hourly Occupation Date Hired Average Weekly Wage Union # Complicating Medical Conditions: i.e. diabetes, high blood pressure, asthma, etc. Accident Information Date Employer Notified Claim is:             No Injury Jobsite Medical Clinic Medical Hospital Released Hospital Inpatient Death Lost Time Modified Duty Accident Description Witnesses Location of Accident Injuries Is this a Questionable Accident? Yes    No Date Returned to Work Subrogation: Is any person, company, or machinery responsible for injury? Yes    No If you answered Yes to last question, please give details: Any Additional Information

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