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FIRST REPORT OF INJURY REFERRAL
To download this form please
click here
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Preparer's Information
Type of Claim:
Report Only
Telephonic Case Mgmt
Field Case Mgmt
Your Name*
Your Email*
Date*
Time
Name Of Company/Employer*
Name of Employer Contact*
Employer Phone*
Site Of Employment*
Injured Employee
Name*
Phone
Address*
City*
State*
Zip Code*
Date of Birth*
Social Security Number
Occupation
Department
Employment Status
Full Time
Part-Time
Per Diem
# Of Hours
Salary
# Of Dependents
Marital Status
Single
Married
Divorced
Widowed
Insurance Carrier
Date Of Loss
Date Reported
To Whom
Date Last Worked
Date Last Paid
Date Reported
Date Return To Work
Injury Information
Date Of Injury*
Time Of Injury*
Location Of Injury*
How Did The Injury Occur*
Were there any witnesses?
Yes
No
If Yes, Name(s)
Were There Any Prior Injuries?
Yes
No
Where Did The Employee Go For Immediate Treatment?
Date treated*
Treatment Info
Is Follow-Up Treatment Needed?
Yes
No
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