Work Injury Report Step 1 of 14 7% PhoneThis field is for validation purposes and should be left unchanged. 👋 Member recognized! To keep your data secure, please log in to auto-fill the rest of this form. Log In to Auto-Fill Email First NameLast NamePhone When did the injury happen?Date of Incident MM slash DD slash YYYY Time of Incident Where at work did this happen? Tell us about your employerEmployer/Company NameThis field is hidden when viewing the formGeocoder CEmployer Address Your Job TitleSupervisor NameSupervisor Phone What happened? Which body part(s) were injured? Select All Head Neck Back Shoulder Arm Hand/Wrist Hip Leg Knee Foot/Ankle Other * Select All That Apply Did you report this to your employer? Yes No Has a workers' comp claim been filed? Yes No Did you receive medical attention? Yes, ambulance came Yes, went to ER Yes, saw a doctor Yes, went later No Not sure yet Are you still receiving treatment? Yes No Have you missed work due to this injury? Yes No Are you still employed there? Yes No Your Injuries Take picture of injury, workplace, incident reports, medical records Take picture of injury, workplace, incident reports, medical records Drop files here or Select files Accepted file types: jpg, gif, png, jpeg, pdf, Max. file size: 80 MB, Max. files: 10. Upload picture of injury, workplace, incident reports, medical records Drop files here or Select files Accepted file types: jpg, gif, png, jpeg, pdf, Max. file size: 80 MB, Max. files: 10. Any witnesses? Yes No Witness #1 NameWitness #1 PhoneWitness #2 NameWitness #2 PhoneWitness #3 NameWitness #3 PhoneWitness #4 NameWitness #4 Phone Anything else we should know?Provide any information you think may be important Review Your Report Please review the information below before submitting. You can go back to any previous step to make corrections. {all_fields} Important: By confirming and submitting this report, you explicitly allow an attorney or their agent from Labor Advocate Law to call you at the number provided to discuss your matter.
