IN THE EVENT OF A WORKPLACE INJURY:
Injured employee must immediately report injury to site Supervisor.
EMPLOYEE INFORMATION
Workplace Location
*
Please Select
Aiea, HI
Albuquerque, NM
Albuquerque DFS
Alpharetta DFS
Armonk, NY
Armonk DFS
Atlanta, GA
Austin DFS
Bakersfield, CA
Bangor, ME
Baton Rouge, LA
Beaumont, TX
Boston, MA
BOSTON DFS
Burbank, CA
Carson, CA
Colchester, VT
Columbus, GA
Chattanooga, TN
Dallas DFS
Decatur, IL
Denver DFS
East Point DFS
Elizabeth, NJ
Elk Grove DFS
Fargo, ND
Flagstaff, AZ
Frederick, MD
Frisco DFS
Grand Junction, CO
Grove City, OH
Hamilton, OH
Harrisburg, PA
Hartford, CT
Helena, MT
Hicksville, NY
Houston, TX
Houston DFS
Idaho Falls, ID
Imperial, PA
Jackson, MS
Jacksonville, FL
Kansas City DFS
Knoxville, TN
Lacey, WA
Las Vegas MDO, NV
Louisville, KY
Lubbock
Macon, GA
Marysville, WA
McAllen, TX
Medford, OR
Miami DFS
Miami Flatbed
Midland, TX
Milton, VT
Missoula, MT
Nampa, ID
Newark, CA
Newark DFS
Newark, NJ MDO
New Haven, IN
Norton, MA
Ocala, FL
Phoenix, AZ
Phoenix DFS
Pittsburgh DFS
Pomona, CA
Pomona LineHaul
Portland, ME
Portland, OR
Portland, OR DFS
Portland DFS
Puerto Rico DFS
Rancho Cordova, CA
Rawlins, WY
Richmond, CA
Richmond DFS
Rutherford, NJ
Sacramento, CA
Sacramento/Reno DFS
Salem, OR
Salem, VA
San Diego, CA
Sanford, FL
San Juan, PR
Santa Barbara, CA
Schuyler, NY
Scott Depot, WV
Seattle, WA
Seattle DFS
Sioux City, SD
Sisters, OR
Spokane, WA
Spokane DFS
Strafford, MO
Stonecrest Flatbed
ST Luis DFS
Suitland, MD
Syracuse, NY
Tracy, CA
Tucson, AZ
Upstate NY DFS
Youngstown, OH
Patient Name
*
First Name
Last Name
Social Security Number
*
Date of Birth
*
-
Month
-
Day
Year
Date
Average Weekly Wage
*
Date of Hire
*
-
Month
-
Day
Year
Date
Date of Injury
*
-
Month
-
Day
Year
Date
Time of Injury
*
Hour Minutes
AM
PM
AM/PM Option
Last Day EE Worked
*
-
Month
-
Day
Year
Date
Was EE Paid For The Full Day On DOI?
*
Please Select
Yes
No
Has EE Returned to Regular Work?
*
Please Select
Yes
No
Date of Return to Work
-
Month
-
Day
Year
Date
Was EE Sent for Medical Treatment
*
Please Select
Yes
No
If so, Name of Medical Facility
Employer Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Location Phone Number
*
Please enter a valid phone number.
DOI Reported
*
-
Month
-
Day
Year
Date
Authorized by
*
First Name
Last Name
Title
*
Phone Number
*
Please enter a valid phone number.
Date
*
-
Month
-
Day
Year
Date
Form 1 - Employee’s Report of Injury Informe de Lesion del Empleado
Please complete and submit no matter how minor the injury. Por favor completer y enviar por mas pequena quesea la lesion.
Name (First, Last) Nombre (Primero, Apellido):
*
First Name
Last Name
DOB/FDN:
*
-
Month
-
Day
Year
Date
SSN/numeros SS:
*
Phone Number
*
Please enter a valid phone number.
Street Address Direccion:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client Assignment (Name) Asignacion del cliente (Nombre):
*
Job Title Titulo de Trabajo:
*
Supervisor’s Name Nombre del Supervisor:
*
First Name
Last Name
Date of injury Fecha de la lesion:
*
-
Month
-
Day
Year
Date
Time of Injury Hora de la lesion:
*
Hour Minutes
AM
PM
AM/PM Option
Date Injury Reported Fecha de reporte delesion:
*
-
Month
-
Day
Year
Date
Who was the injury reported to? (Name) Conquien reporto la lesion? (Nombre)
*
Last Day Worked Ultimo diatrabajado:
*
-
Month
-
Day
Year
Date
Where did the injury occur? (Warehouse, break room, parking lot, maintenance shop, yard, etc)Donde ocurrio la lesion? (Bodega, sala de Descanso, estacionmiento, area demantenimiento, etc)
*
How did the injury occur? Como ocurrio la lesion?
*
Type of injury (cut, strain, sprain, broken, etc) Tipo de lesion (cortado, torcedura, esguinces, rotura, etc):
*
Part of Body Parte del cuerpo
*
What object or substance caused the injury? Que objeto o sustancia causo la lesion?
*
Have you received any treatment? If so, what kind? Has recivido algun tratamiento? Si es asi, que tipo?
*
Who witnessed the accident? Quien fue testigo del accidente?
*
Was the injury caused by someone else? Fue la lesion causado por alguien mas?
*
Please Select
Yes
No
If yes, Name Si es si, Nombre:
*
Did the accident involve employees or equipment from another company? El accidente involucro empleados o equipo de otra compania?
*
Please Select
Yes
No
If yes, Name(s) Si es si, Nombre(s):
*
What actions (if any) were taken to prevent similar accidents from occurring? Que acciones (si las hay) se tomaron para evitar que ocurran accidents similares?
*
Have you had a Workers’ Comp claim in the last year? Has tenido algun reclamo de compensacion al trabajador en el ultimo ano?
*
Please Select
Yes
No
If Yes, when Si es si, cuando:
*
Have you had a previous injury to this body part? Has tenido alguna lesion previa en esta parte del cuerpo?
*
Please Select
Yes
No
If Yes, when Si esasi, cuando:
*
Note: Any person who knowingly provides false, incomplete or misleading information to any party for the purpose of obtaining workers' compensation benefits is guilty of a felony and may be subject to imprisonment, fines and denial of insurance benefits. Nota: Cualquier persona a sabiendas proporciona informacion falsa, incomplete o enganosa a cualquiera de las partes con el fin de obtener beneficios de la compensacion al trabajador es culpable de un delito y puede estar sujeto a prision, multa y la negacier de beneficios del seguro.
Employee Name (print) Nombre del empleado:
*
First Name
Last Name
Signature Firma:
*
Date Fecha:
*
-
Month
-
Day
Year
Date
FORM 2 - CONSENT FOR RELEASE OF MEDICAL INFORMATION EMPLOYEE
I hereby authorize representatives of company, carrier and consultants to be permitted to obtain and review copies of all medical records related to any current or past injury or related to my medical history. Any pertinent information will be discussed with other professionals involved in my medical treatment and any institution that, through the “Workers’ Compensation Program” or otherwise, is paying all or part of the costs associated with my medical care.
Employee Name
*
First Name
Last Name
Social Security Number
*
Phone Number
*
Please enter a valid phone number.
Claim Number
Name of Employer
*
Date of Injury
*
-
Month
-
Day
Year
Date
Signature
*
Date
*
-
Month
-
Day
Year
Date
FORM 3 - Work Related Injury Supplemental Information Required by the Carrier
1. Was the DWC-1 given to EE within 24 hrs?
*
Please Select
Yes
No
2. Supervisors name
*
First Name
Last Name
3. Supervisors Phone Number:
*
Please enter a valid phone number.
4. Injured EE Job Title:
*
5. Has employee returned to regular work schedule without EE losing time:
*
Please Select
Yes
No
6. Day last worked once injury occurred:
*
-
Month
-
Day
Year
Date
7. Day returned to work after injury occurred
*
-
Month
-
Day
Year
Date
8. Witnesses:
First Name
Last Name
9. Date of injury
*
-
Month
-
Day
Year
Date
10. How did injury occur
*
11. What body parts were injured:
*
12. Who was injury reported to:
*
First Name
Last Name
13. Was EE sent for medical treatment:
*
Please Select
Yes
No
14. If Yes, where?
15. Employee Phone Number
*
Please enter a valid phone number.
16. Any known prior injuries
*
17. Modified Duty Available
*
18. Is ER disputing claim:
*
Please Select
Yes
No
19. Date of hire
*
-
Month
-
Day
Year
Date
20. No. of employees:
*
FORM 4 - Supervisor’s Report of Injury And Root-Cause Analysis
Please complete and submit no matter how minor the injury.
Injured Employee Name:
*
First Name
Last Name
Client Company Name:
*
Date of Injury:
*
-
Month
-
Day
Year
Date
Time of Injury:
*
Hour Minutes
AM
PM
AM/PM Option
Date Injury Reported:
*
-
Month
-
Day
Year
Date
Who was the injury reported to?
*
Last Day Worked:
*
-
Month
-
Day
Year
Date
Was the employee performing assigned duties?
*
Please Select
Yes
No
Where did the injury occur?
*
(Warehouse, break room, parking lot, maintenance shop, yard, etc)
What was the employee doing when the injury occurred?
*
How did the injury occur?
*
What was the Root Cause of this incident?
*
What corrective actions were taken (in regards to the EE)?
*
What corrective actions were taken (in regards to the workforce)?
*
Type of injury (cut, strain, sprain, broken, etc):
*
Part of Body:
*
What object or substance caused the injury?
*
Has employee received any treatment? If so, what kind?
*
Who witnessed the accident?
*
Was the injury caused by someone else?
*
Please Select
Yes
No
If yes, Name:
*
First Name
Last Name
Did the accident involve employees or equipment from another company?
*
Please Select
Yes
No
if yes, Name
*
First Name
Last Name
What actions (if any) were taken to prevent similar accidents from occurring?
*
What (if any) safety procedures were violated?
*
Why did the incident happen?
*
Inadequate guard
Unguarded hazard
Safety device is defective
Tool or equipment defective
Workstation layout is hazardous
Unsafe lighting
Unsafe ventilation
Not using personal protective equipment
Lack of appropriate equipment/tools
Inappropriate use of equipment/tools
Unsafe clothing
Insufficient/no training
Not following instructions
Operating without permission
Operating at unsafe speed
Servicing equipment that has power to it
Making a safety device inoperative
Using defective equipment
Using equipment in an unapproved way
Unsafe lifting by hand
Taking an unsafe position or posture
Distraction
Teasing
Horseplay
Other
Please include any additional comments you feel are important
*
Supervisor Name:
*
First Name
Last Name
Supervisor Signature
*
Date
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
RISK CONNECT COMPLETE?
*
Please Select
YES
NO
RISK CONNECT CLAIM NUMBER
*
Submit
Should be Empty: