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*

MaleFemale
Marital Status*

MarriedSingle
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?*

YesNo
Address where injury occured?

Street Address

Street Address Line 2

CityState

Zip Code
Were safeguards or safety equipment provided?*

YesNo
Were safeguards or safety equipment used?*

YesNo
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?*

YesNo
Select the approved provider the injured team member is/will be visiting.
Was there a witness to the event?*

YesNo
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