SWIF Claim Number
SWIF Claim Number
Fire Department Injury Reporting Form
Complete the following form with the information of the injured person.
Injured Person's First Name
*
Injured Person's Last Name
*
Injured Person's Email
*
Confirmation Email
Date of Injury
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
The date the injury was sustained
Time of Injury
*
AM
PM
AM/PM Option
Job Title
*
SSN
*
Birth Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Hire Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Gender
*
Male
Female
Marital Status
*
Married
Single
Dependents
Employment Status
*
Please Select
Full-time
Part-time
Seasonal
Volunteer
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Zip Code
Phone Number
*
Format: (000) 000-0000.
County
*
Shift Start Time
*
AM
PM
AM/PM Option
Employer Notified Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Last Day Worked
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date Returned to Work
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Type of Injury or Illness
*
Provide as much detail as possible, your claim could be denied due to insufficient information!
Parts of Body Affected
*
Cause of Injury
*
Provide as much detail as possible, your claim could be denied due to insufficient information!
Did injury occur on employer's premises?
*
Yes
No
Address where injury occured?
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Were safeguards or safety equipment provided?
*
Yes
No
Were safeguards or safety equipment used?
*
Yes
No
All equipment, materials, chemicals team member was using when accident or illness occurred.
*
Provide as much detail as possible, your claim could be denied due to insufficient information!
How injury or illness occurred. Describe the sequence of events and include any objects or substances responsible.
*
Provide as much detail as possible, your claim could be denied due to insufficient information!
Was treatment sought at this time?
*
Yes
No
Select the approved provider the injured team member is/will be visiting.
Please Select
Concentra Medical Centers; 4910 Ritter Road; Mechanicsburg; 717.795.1819
Patient First; 107 S. Sporting Hill Rd.; Mechanicsburg; 717.943.1781
Concentra Medical Centers; 6108 Carlisle Pike; Mechanicsburg; 717.691.9560
UPMC Urgent Care; 6481 Carlisle Pike; Mechanicsburg; 717.796.9355
[ER] UPMC Harrisburg ED; 111 S Front St; Harrisburg; PA 17101; 717.782.5258
Concentra Medical Centers; 4200 Union Deposit Rd.; Harrisburg; 717.558.6708
UPMC Urgent Care; 1175 Walnut Bottom Road; Carlisle; 717.258.9355
Was there a witness to the event?
*
Yes
No
Witness
First Name
Last Name
Witness Phone Number
Format: (000) 000-0000.
Policy Start Date
Policy End Date
Submission Date
.
Year
.
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
SWIF Contact
Policy Number
Kristopher Kaminski
Tom Shumberger
Submit
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