• EMPLOYEE INCIDENT REPORT

  • Strategic Focus Clear Vision. Defined Strategy. Proven Results.

  • 3540 E. Broad St. Store 6870 #126 Mansfield, Tx 76063

    Phone 214-888-6776 Fax: 1 214 833 7257 Email: claims@stratfocusllc.com

    All claims should be reported to Strategic Focus within 24 hours of any reported employee incident.

    Email the completed forms to claims@stratfocusllc.com/ Fax: 1 214 833 7257

  • D THIS FORM TO BE COMPLETED BY THE EMPLOYEE

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  • DETAILS OF INCIDENT

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  • If Yes, please provide detail below:

     

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  • Any person who, knowingly and with intent to injure, defraud, or deceive any employer, employee or insurance company, files a statement of claim containing any false or misleading information is guilty of a felony of the third degree. / have reviewed, understand and acknowledge the above statement.

  • Clear
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  • Should be Empty: