Employee’s First Report of Injury
(To be completed by employee at time of accident)
WC Policy No. 910920 IWIF CLAIM #:
Employee Name: EMPL ID: ___________
Last First Middle
Date of Birth: Marital Status: No. of Dependents: ___
Regular Contingent (circle one) Full Time Part Time (circle one): _______%
Home Address: ________________________________________________ Phone: _________
Street City State Zip Code
Supervisor: ____________________ When Accident reported to Supervisor: _______________
Accident Date: Time: am pm Time Shift Began:_________
Accident Location: ______________________________________________________________
Bldg. Address Area(hallway, etc.)
Describe fully how accident occurred (your activities at that time): ________________________
List injured body parts (be sure to indicate “right” or “left” side): _________________________
Was medical treatment sought? If so, where: _________________________________________
Name Address
City State Zip Code Phone
Safety equipment (list items in use): ________________________________________________
Name(s) of witness(es): __________________________________________________________
Name Phone
Not valid unless signed. By signing this form, I acknowledge that all statements made
herein are true and correct to the best of my knowledge.
Signature of employee: Date: _____________
*Fax Immediately to: EHS Risk Management, (410) 706-8212*
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