REPORT AN INJURY Preparer Information Preparer's Name Preparer's Phone Preparer's Title Preparer Is Agent CarrierAdmin Carrier Admin Co-Worker Employer InjuredWorker Other Date Prepared Preparer's Email Employer Information Employer Name Address City State Zip Phone Fax Nature of Business Contact Person Contact Phone Contact Email Employee Information First Name Last Name Address City State Zip Home Phone Cell Phone Social Security Date of Birth Age Gender Male Female Marital Status Single Married Divorced Widowed Total Dependents Occupation Department Date of Hire Employee Status Days Worked Per Week Time Shift Begins (Indicate AM/PM) Time Shift Ends (Indicate AM/PM) Wages Day Week Month Year Other If Wages Other, Units and Avg Units/Day: Date Injury Reported to Employer Has Employee Returned to Work? YesNo Date and Time of Return to Work Paid for the day of injury? YesNo Paid While Injured? YesNo Accident Information Accident Date and Time Accident Location (address/department) Accident Description Work Process Employee Engaged In at Time of Accident Were Safeguards Provided? YesNo Were Safeguards Used? YesNo Was Accident on Premises? YesNo Date Worked Is this claim for reporting purposes only? YesNo Lost Time claim? YesNo Was the accident fatal? YesNo If Fatal, Date of Death Nature of Injury/Body Part Object/Substance Involved Name of Witness Medical Provider Information Provider Name Address City State Zip Phone Initial Treatment None By Employer Minor Clinic/Hospital Emergency Care Hospitalized > 24 Hours Future Major Medical/Lost Time Anticipated Mode of Transportation Not Applicable Own Car Other Vehicle Ambulance MedEvac Other Did injury occur more than 3 days ago? YesNo If Yes, list reason for delay Is there a reason to place this claim under investigation? YesNo If Yes, list reason Comments © 2021 Medlogix®. All rights reserved. Terms of Use Privacy Policy Site Map V1.1.15.18 ABOUT Leadership Press Blog Careers Contact Us SERVICES Workers’ Comp Auto Medical Group Health NJ Auto Plans OUR TECHNOLOGY MyMedlogix™ MedlogixU™ CHN PPO™ MEG Integrity twitter linkedin

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