Workers Compensation Loss Report Please fill out the form below. Items marked with an asterisk(*) are mandatory fields. Employer Details Employee Details Injury Details Hospital Details Reporting Person Details Employer Details Policy Number: Employer Street Address: Employee Date of Hire: Employer City: Name of the Employer:* Employer State: -Select State- AK AL AR AS AZ CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PI RI SE SD TN TX UT VI VT VA WA WI WV WY Other.. Employer Phone Number:* Employer Zip Code: Employer E-Mail Address: Employee Details Employee First Name:* Employee Work Location Address: Employee Middle Name: Employee Work Location City: Employee Last Name:* Employee Work Location State:* -Select State- AK AL AR AS AZ CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PI RI SE SD TN TX UT VI VT VA WA WI WV WY Other.. Employee Sex: Male Female Employee Work Location Zip Code: Employee Home Address: Employee SSN: Employee City: Employee DOB: Employee State: -Select State- AK AL AR AS AZ CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PI RI SE SD TN TX UT VI VT VA WA WI WV WY Other.. Employee Occupation: Employee Zip Code: Employee Phone Number: Injury Details Date of Injury or Occupational Disease:* Time of Injury: HH 01 02 03 04 05 06 07 08 09 10 11 12 MM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 AM PM Date Reported to Employer: Describe in detail nature and extent of injury, indicate part of body involved:* How did the accident occur?:* Was Worker admitted to Hospital?: Yes No Unknown Loss Location Address: Date admitted to Hospital: Loss Location City: Did the accident result in a fatality? Yes No Unknown Loss Location State: -Select State- AK AL AR AS AZ CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PI RI SE SD TN TX UT VI VT VA WA WI WV WY Other.. Was Accident or last exposure on Employer Premises?: Yes No Unknown Hospital Details Hospital Name: Physician Or Clinic Name: Hospital Phone Number: Physician Or Clinic Phone Number: Hospital Street: Physician Or Clinic Street: Hospital City: Physician Or Clinic City: Hospital State: -Select State- AK AL AR AS AZ CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PI RI SE SD TN TX UT VI VT VA WA WI WV WY Other.. Physician Or Clinic State: -Select State- AK AL AR AS AZ CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PI RI SE SD TN TX UT VI VT VA WA WI WV WY Other.. Hospital Zip Code: Physician Or Clinic Zip Code: Reporting Person Details Reporting Person Name:* Reporting Person Phone Number:* Reporting Person Role:* --Select Role-- Agent Claimant Attorney Doctor Employee/Claimant Employer Other State Security Code:* (For added security, please enter the code displayed on the right, into the lower text box) Please enter text shown above
