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
Time of Injury
*
Minutes
AM
PM
AM/PM Option
Job Title
*
SSN
*
Birth Date
*
/
Month
/
Day
Year
Date
Hire Date
*
/
Month
/
Day
Year
Date
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
Postal / Zip Code
Phone Number
*
County
*
Work Start Time
*
24 Hour Clock
Employer Notified Date
/
Month
/
Day
Year
Date
Last Day Worked
*
/
Month
/
Day
Year
Date Returned to Work
*
/
Month
/
Day
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
Were safeguards or safety equipment provided?
*
Yes
No
Were safeguards or safety equipment used?
*
Yes
No
All equipment, materials, chemicals employee 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?
*
Please Select
No Treatment
Minor by Employee
Clinic/Hospital
Panel Physician
Employee Physician(PCP)
Emergency Care
Hospitalized for more than 24 hours
Physician First Name
Physician Last Name
Physician Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Hospital/Clinic Name
Hospital/Clinic Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Policy Number
Policy Start Date
Policy End Date
Was there a witness to the event?
Yes
No
Witness
First Name
Last Name
Witness Phone Number
SWIF Contact
Submit
Should be Empty: