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<Report OnlyTelephonic Case MgmtField Case Mgmt
Preparer's Name*
Preparer's Phone Number*
Preparer's Title*
Date Prepared*
Preparer's Email*
Policy Number
Benefit State
Accident Date*
Accident Time*
Name*
Federal Employer Identification(FEIN)
State UI Registration #
Address*
City*
State*
Zip Code*
Phone Number*
Nature of business
Contact Person*
Contact Phone Number*
YesNo
First Name*
Last Name*
Phone*
Social Security #
Age
Date of Birth*
If employee is under age 18, please enter certificate #
Gender
MaleFemale
Marital Status
SingleMarriedDivorcedWidowed
Occupation*
Department
Hire Date
State of Hire
Date in Current Job
Length in Current Job
Date Injury Reported to Employer*
Employee Status
Full TimePart TimeVolunteerSeasonalOther
Is the Employee Owner/Officer, Partner?
Was employee paid for the day of injury?
Days Worked/Week
Hours Worked/Day
Hours Worked/Week
Wages/Hour
Wages/Day
Average Gross Wage/Week
Salary/Mont
Has Employee Returned to Work?
If Yes, Indicate Date & Time
Return Wage
Paid while injured?
Total Dependents
Accident Location (address/department)
Accident County
Accident Description*
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)
Supervisor
Date Last Worked
Is this a Lost Time Claim?
Fatal?
If Yes, date of death
If yes, name and address of nearest relative
Did Employee Commit an Unsafe Act?
Object/Substance Involved
Reason to doubt validity of claim?
Witness Name
Address
City
State
Zip Code
Phone Number
Is This Claim For Reporting Purposes Only?
Provider Name
Was Employee Treated In An Emergency Room?
Was Employee Hospitalized Overnight?
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