No

Everything you need to report a workplace injury

  • Gather all the information needed for filing your report prior to calling the quick care report line. 
  • At the end of your call, make note of your call confirmation number for future reference.

Employer

  • Name of company, contact person, phone number
  • Policy number
  • Mailing address (complete), mailing location code
  • Telephone number (include area code)
  • Injury location (if different from mailing address), injury location code
  • Type of business, SIC code
  • Tax ID number
  • Unemployment insurance account number
  • Second employer (if applicable)
  • Second employer average weekly wage

Employee

  • First name, middle initial, last name
  • Social Security Number
  • Date of birth
  • Home address (complete)
  • Telephone number (include area code)
  • Gender
  • Occupation (regular job title)
  • Date of hire
  • Usual number of hours, days/week worked 
  • Employment status: regular full time, part time, temporary, seasonal, volunteer 
  • Gross wages/salary: $_____  per ______
  • Department
  • Number of dependents
  • Tax filing status
  • ls employee certified as vocationally handicapped?

Injury or illness

  • Date of injury or onset of illness
  • Time injury or illness occurred
  • If employee died, date of death
  • Date employee last worked
  • Date employee returned to work
  • Was employee paid full wages for date of injury?
  • Is employee's salary being continued?
  • Date of employer's knowledge/notice of injury or illness
  • Specific injury or illness, part of body affected, medical diagnosis (if available)
  • Location of event or exposure (complete address)
  • Did event or exposure occur on employer's premises?
  • Specific activity employee was performing when event or exposure occurred
  • How injury or illness occurred (describe sequence of events, object or exposure that directly caused injury or illness)
  • Physician name, telephone number, complete address
  • If hospitalized as in-patient, hospital name, telephone number, complete address
  • Supervisor name
  • Witness name, complete address, phone number

SP327 (3/20)

No

Everything you need to report a workplace injury

  • Gather all the information needed for filing your report prior to calling the quick care report line. 
  • At the end of your call, make note of your call confirmation number for future reference.

Employer

  • Name of company, contact person, phone number
  • Policy number
  • Mailing address (complete), mailing location code
  • Telephone number (include area code)
  • Injury location (if different from mailing address), injury location code
  • Type of business, SIC code
  • Tax ID number
  • Unemployment insurance account number
  • Second employer (if applicable)
  • Second employer average weekly wage

Employee

  • First name, middle initial, last name
  • Social Security Number
  • Date of birth
  • Home address (complete)
  • Telephone number (include area code)
  • Gender
  • Occupation (regular job title)
  • Date of hire
  • Usual number of hours, days/week worked 
  • Employment status: regular full time, part time, temporary, seasonal, volunteer 
  • Gross wages/salary: $_____  per ______
  • Department
  • Number of dependents
  • Tax filing status
  • ls employee certified as vocationally handicapped?

Injury or illness

  • Date of injury or onset of illness
  • Time injury or illness occurred
  • If employee died, date of death
  • Date employee last worked
  • Date employee returned to work
  • Was employee paid full wages for date of injury?
  • Is employee's salary being continued?
  • Date of employer's knowledge/notice of injury or illness
  • Specific injury or illness, part of body affected, medical diagnosis (if available)
  • Location of event or exposure (complete address)
  • Did event or exposure occur on employer's premises?
  • Specific activity employee was performing when event or exposure occurred
  • How injury or illness occurred (describe sequence of events, object or exposure that directly caused injury or illness)
  • Physician name, telephone number, complete address
  • If hospitalized as in-patient, hospital name, telephone number, complete address
  • Supervisor name
  • Witness name, complete address, phone number

SP327 (3/20)