EMPLOYER INCIDENT REPORT

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

Strategic Focus

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

Phone 214-888-6776 Fax: 1 214 833 7257

Email: claims@stratfocusllc.com

THIS FORM TO BE COMPLETED B THE EMPLOYER

EMPLOYER NAME/CLIENT ID

Employer Contact Phone and email address

INJURED WORKER INFORMATION

Name

First Name Last Name

Date of Birth

Date

SS# (Last 4 digits)

Date of Hire

Date

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Job Title

Type a question

Full Time Part Time Seasonal

How many days per week does the employee work?

From

AM PM

To

AM PM

Scheduled Days Off

M T W TH FRI SAT SUN Rotating

Was the employee hired to work 40 hours per week?

Yes No

If no, for how many hours a week was the employee hired?

Last date of work after incident

Date

Start time of shift on date of incident

AM PM

DETAILS OF INCIDENT

Date of incident

Date

Time of incident

AM PM

Location of incident (includes address if different from employer address)

Describe how and why incident/injury occurred

Part(s) of the body impacted (Be Specific: e.g., left eye, right forearm, right hand, left lower back)

Type of injury/illness: (Be specific: e.g., cut, bruise, needlestick, strain, burn)

Incident Reported To

Date Reported

Date

Time Reported

AM PM

Witnesses?

Yes No

If Yes, list witnesses