Employee Accident/Incident Report Form

Was this an Incident or an Accident?

Updated Nov 2023, Workers Comp: Work Related Accident or Injury. The premius is paid within Gusto to Next Insurance which is our Agent. https://app.apintego.com/account/dashboard

Amtrust is the insurance company that Next uses for our Workers Comp.

For an accident or injury follow these steps:

For Severe Emergency Injury:
Assess the Situation:

Quickly evaluate the severity of the injury.
If the person is unconscious, has trouble breathing, severe bleeding, or suspected broken bones, it's a severe emergency.
Call Emergency Services:

Immediately dial local emergency services (e.g., 911 in the U.S.).
Provide clear details about the location and nature of the injury.
Administer First Aid (if trained):

If you're trained in first aid, provide basic support like controlling bleeding or CPR.
Do not move the injured person unless necessary for safety.

For Non-Emergency Injury (Locating Workers' Comp Provider):
Evaluate the Injury:

Assess the nature of the injury.
Determine if it's non-life-threatening and if the person can be moved.
Consult the Workers' Comp Network:

Reference your company's workers' compensation network for approved healthcare providers. The page below has a link to find a nearby in network provider.
https://amtrustfinancial.com/claims
Ensure the injured person or a colleague has access to this information.
Transport to Healthcare Provider:

Arrange for transportation to the healthcare provider.
Accompany the injured employee if possible.
Document the Injury:

Complete an incident report detailing the injury and circumstances.
Include any first aid measures taken.
Notify Office Management and HR:

Report the incident to your superior and HR department.
Follow the company's procedure for handling work-related injuries.

Claims
Please submit claims to the AmTrust Claims Department with the following information:

Name of the insured and policy number
Date, Time & Place of Accident
Description of accident or incident
Name, phone and/or e-mail of the person making the report
The injured employee's social security number
Description of the injury
After the first report is made your carrier will assign you a claims adjuster to assist you going forward with this particular incident. Complete form below and email to amtrust address below.

Amtrust
Email: Amtrustclaims@qrm-inc.com
Phone: (866) 272-9267
Fax: (775) 908-3724
Fax2: (877) 669-9140

Naturalcare Home Cleaning, Inc.
Policy: KWC1305336

Todays Date

MonthDayYear

Name of Person Making Report

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

Date of incident/Accident

MonthDayYear

Name of Injured Person

First NameLast Name

Social Security Number

Description of of What Happened

Please give all detaild

Any Injuries?

Where (actual location of incident/Accident)

Download Picture Here

Browse Files

Please send several pictures if you can

Witnesses (were there any and if so do you have statements?)

Witness/Witnesses Names

Employee Incident/Accident Report Form