EMPLOYER INFORMATION

Policy Number

Policy Term

From To

Nature of Business (Tribal Government, Casino, etc.)

Employer Name *

Employer Address *

Employer City *

Employer State *

Employer Zip Code *

Contact Person Name *

Contact Person Title

Contact Phone No *

Contact Person Email

Contact Fax No

Name of Person Completing Report

Title of Person Completing Form

Phone Number of Person Completing Form

Email of Person Completing Form

Date Completed

Signature * By typing your initials, you are signing this form electronically.

EMPLOYEE INFORMATION

Last Name *

First Name *

M.I.

Suffix

Sex

Birth Date *

Social Security Number *

Phone No. *

Email Address

Home Address (Number & Street) *

City *

State *

Zip Code *

Employee's Job Title When Injured

Employee's Assigned Department

DESCRIPTION OF ACCIDENT

Date of Injury *

Time of Injury

Last Day of Work After Injury

Date of Return to Work

Date Employer Notified of Lost Time

Date Employer Notified of Injury *

Address or Location of Accident *

On Employer Premises?

Yes

No

Was Injury Fatal? *

Yes

No

City *

State *

Zip Code

Cause of Injury *

Nature of Injury *

Part of Body Injured *

Emergency Room, Hospital or Medical Facility

Treated by (Name, Address & Phone)

How Did Accident Happen? What was Employee Doing When Accident Occurred? (State all details)

If Validity of Claim is Doubted, State Reason

EMPLOYEE'S WAGE DATA

Was Worker in Your Employ When Injured?

Date of Last Hire

Hours per Day Employee Worked:

From

To

Number of Days Per Week:

Employee's Wage

Personal Time Off During the 26 calendar weeks preceding injury

Employee Injury Report

EMPLOYER INFORMATION

EMPLOYEE INFORMATION

DESCRIPTION OF ACCIDENT

EMPLOYEE'S WAGE DATA