Workers Compensation Report Of Injury To Risk Management

• Person filing on behalf of work location

• Your Name

  Your Name First Last
• Your Email
• Your Location

• This section is regarding injured employee

• Injured Employees number(munis ID - 5 digits)
• Injured Employees Name

  Injured Employees Name First Last
• Injured Employees Job Title
• Date Of Injury

  Date Of Injury / MM / DD YYYY

  
• Date Injury Was Reported By Employee

  Date Injury Was Reported By Employee / MM / DD YYYY

  
• Location Of Injury
• School/Location Phone Number

  School/Location Phone Number - ### - ### ####
• Body Part(s)Injured
  Body Part(s)Injured

  Head Neck Shoulder(s) Arm(s) Leg(s) Foot(feet) Hand(s) Back Ankle(s) Finger(s) Eye(s) Face Whole Body Miscellanous
• Report only or open claim
  Report only or open claim

  Report only - no treatment being saught Open claim - employee seeking(saught) treatment
• Accident Description(please include any details needed)