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Add New Incident

What is the Nature of Incident?*

Vehicular

Non-Vehicular

Company name*

Today's Date*

Shift Start Time*

Time

:HoursMinutes

Employee Details:

First name*

Last name*

Email Address*

Job Position/Title*

Contact Number*

Date of Birth*

FICO Score

Station Code/Job Site

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Supervisor Details:

Did you notify your supervisor?*

Yes

No

Incident Details:

Date of Incident*

Time of Incident*

Time

:HoursMinutes

Location where the incident happened*

What was employee doing when the incident happened*

Is Third Party present?*

Yes

No

Was there a Police Report taken for this incident?*

Yes

No

Driver's Statement*

Unsafe Conditions

Witnesses?*

Yes

No

Injuries Details:

Were there any Injuries?*

Yes

No

Vehicle Details:

Select Vehicle Type*

Declaration & Submission:

Attachments (add up-to 20 files)*

Signature*

Sign in the box or use the keyboard to type.

Signature field is empty.

I certify that the information given above is true, correct, and accurate.

I understand that it is unlawful to knowingly assist, abet, conspire with, or solicit a person to file a fraudulent workers’ compensation claim.

All questionable claims will be investigated and violators will be punished to the full extent of the law.

PRIVACY

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