Fire Department Injury Reporting Form

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

MonthDayYear
The date the injury was sustained
Time of Injury

AM/PM Option
Job Title
SSN
Birth Date

MonthDayYear
Hire Date

MonthDayYear
Gender
Marital Status
Dependents
Employment Status
Address

Street Address

Street Address Line 2

CityState / Province

Zip Code
Phone Number
Format: (000) 000-0000.
County
Shift Start Time

AM/PM Option
Employer Notified Date

MonthDayYear
Last Day Worked

MonthDayYear
Date Returned to Work

MonthDayYear
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?
Address where injury occured?

Street Address

Street Address Line 2

CityState

Zip Code
Were safeguards or safety equipment provided?
Were safeguards or safety equipment used?
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?
Select the approved provider the injured team member is/will be visiting.
Was there a witness to the event?
Witness

First NameLast Name
Witness Phone Number
Format: (000) 000-0000.
Policy Start Date
Policy End Date
Submission Date

YearMonthDay
Date
SWIF Contact
Policy Number
Kristopher Kaminski
Tom Shumberger
Should be Empty:

SWIF Claim Number

Fire Department Injury Reporting Form