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<Report OnlyTelephonic Case MgmtField Case Mgmt
Preparer's Phone Number*
Federal Employer Identification(FEIN)
State UI Registration #
Nature of business
Contact Phone Number*
Social Security #
Date of Birth*
If employee is under age 18, please enter certificate #
State of Hire
Date in Current Job
Length in Current Job
Date Injury Reported to Employer*
Full TimePart TimeVolunteerSeasonalOther
Is the Employee Owner/Officer, Partner?
Was employee paid for the day of injury?
Average Gross Wage/Week
Has Employee Returned to Work?
If Yes, Indicate Date & Time
Paid while injured?
Accident Location (address/department)
List All Equipment Employee Was Using at Time of Accident
Work Process Employee Engaged In at Time of Accident
Were safeguards provided?
Were safeguards used?
Was Accident on Premises?
Time Shift Begins (Indicate AM/PM)
Time Reported (Indicate AM/PM)
Date Last Worked
Is this a Lost Time Claim?
If Yes, date of death
If yes, name and address of nearest relative
Did Employee Commit an Unsafe Act?
Reason to doubt validity of claim?
Is This Claim For Reporting Purposes Only?
Was Employee Treated In An Emergency Room?
Was Employee Hospitalized Overnight?
2740 Route 10 West
Morris Plains, NJ 07950
Office Center Drive
Fort Washington, PA 19034
Ph: 800 247-3422
Fax: 267 513-1984