Fields marked * are required. Everything else you can leave blank if you don't know it — we can fill gaps later. This form is confidential and used solely to evaluate your claim.
Alternative telephone — a friend, relative, or neighbor we can reach you through.
We do not collect Social Security numbers through this form. If we need it, we'll take it by phone or in person.
Include as much detail as you can remember — what you were doing, what went wrong, and who was present.
Employer's workers' compensation carrier, if known. Leave blank if you're not sure.