First Report of Injury

First Report of Injury

 

Complete the form below and hit “Submit.”

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Time of Injury
:
Lost Time?(Required)
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Account #: 2072013 Policy #: 0201213
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Employee's Name
Employee's Address(Required)
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Gender
Injured on Premises?(Required)
Was Injury Fatal?(Required)
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Did you direct employee to a medical provider?(Required)
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