Report an Injury
Name
First Name
Last Name
Social Security Number (required to file incident/injury with WSI)
*
Date of Birth (mm/dd/yyyy)
*
Date Incident Occurred (mm/dd/yyyy)
Time of Incident
Employee's Normal Shift (Ex: M-F 8am-5pm)
Address ( where injury occured)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Address (employee address)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
Does your injury require medical attention?
*
Yes
No
Unsure
What part of your body was injured (IE right thumb, left elbow)
*
Describe the type of injury (IE laceration on right hand, sprain to left ankle)
*
Describe what caused the injury?
Take Photo of injury and surrounding areas
*
Take Photo of rooms/area you were working when injury happened.
*
Submit
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