Preparer InformationPreparer's Name First Last Preparer's Phone Preparer's Title Date Prepared MM slash DD slash YYYY Preparer's Email Is this claim for reporting purposes only? Yes No Did injury occur more than 3 days ago? Yes No Employer InformationEmployer Name Address City State Zip Phone Employee InformationFirst Name Last Name Address City State Zip Home Phone Cell Phone Social Security Date of Birth MM slash DD slash YYYY Age GenderMaleFemaleMarital StatusSingleMarriedDivorcedWidowedTotal Dependents Occupation Department Date of Hire MM slash DD slash YYYY Employee StatusPiece WorkerVolunteerSeasonalApprentice - IApprentice - IFull-TimePart-TimeNot EmployedRetiredOn-StrikeDisabledOtherDays Worked Per Week Time Shift Begins (Indicate AM/PM) Time Shift Ends (Indicate AM/PM) Wages Date Injury Reported to Employer MM slash DD slash YYYY Has it been more 14 days since the accident occured? Yes No List reason for delay Has Employee Returned to Work? Yes No Date and Time of Return to Work Paid for the day of injury? Yes No Paid While Injured? Yes No Accident InformationAccident Date MM slash DD slash YYYY Accident Time Accident Location (address/department) Accident DescriptionWork Process Employee Engaged In at Time of Accident Were Safeguards Provided? Yes No Were Safeguards Used? Yes No Was Accident on Premises? Yes No Date Last Worked MM slash DD slash YYYY Was the accident fatal? Yes No Date of fatality MM slash DD slash YYYY Nature of Injury/Body Part Object/Substance Involved Name of Witnesses Medical Provider InformationProvider Name Address City State Zip Phone Comments