TPA Reference No. Agency use only
Incident No.:
Claim No.:
Rev 02/2017
1. Agency Location Code 2. Division/Region
4. Employee Number
6. Home Address (City or Town) (State) (Zip) 7. Home Telephone 8. Date of Birth 9. Sex
11. Date of Hire 12. Date of Incident 13. Time of Incident
15. Date Employer Notified
16. Time Injured Worker Began
Work
______ AM PM
17. Was Injury Fatal?
. YES NO
21. Body Part(s) Affected
5. Name of Injured Worker (First) (Last) (MI)
10. Job Classification (Title)
14. Time Employer Notified
19. How Did the Injury Occur?
The Supervisor must complete this form with the injured worker and then forward it along with the
balance of the claim forms to the Human Resources/Workers' Compensation Office within 24 hours.
22. Did Injury Occur on Employer Premises? YES NO
23. Location Injury Occurred
24. Injured Worker Seeking Medical Treatment YES NO
If Yes Complete Questions 25-27
25. Medical Care Provided By: (Physician Name and Address)
26. Was Injured Worker
Treated in an Emergency Room?
YES NO
27. Was Injured Worker
Hospitalized Overnight as an In-Patient?
YES NO
31. Signature of Supervisor (or other Designated Authority) PRINT NAME: DATE:
32. Date Injury Phoned In To 800-828-2717
Supervisors Report All Injuries - Call 1-800-828-2717
28. Were There Any Witnesses to the Injury? YES NO (If yes, give name, address, and phone)
29. To What Supervisor Was Injury Reported? (Name) (Title)
30. Supervisor
Contact Info
Please Print
