Gensuite Submission

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*

Address

City

State

Zip / Postal Code

Incident Details:

Date of Incident*

Time of Incident*

Time

:HoursMinutes

Has the driver returned to work?*

Yes

No

Return to Work date

Work Restriction*

Yes

No

Restriction Start Date

Restriction End Date

Location where the incident happened*

What was employee doing when the incident happened*

Driver's Statement*

Unsafe Conditions

Injuries Details:

Were there any Injuries?*

Yes

No

Declaration & Submission:

Attachments (add up-to 20 files)*

Signature*

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

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

555 Broadhollow rd, Suite 305, Melville, NY 11747 admin@acuityriskconsultants.com

bottom of page

Gensuite Submission

Copyright © 2025 All Rights Reserved