Employee’s Report of Incident

Employee's Report of Incident

Step 1 of 4

Have you reported this incident directly to your employer?*
- Yes
- No
You may continue with this online submission; however, you must report this incident directly to your employer as soon as possible. Failure to follow your employer’s workplace injury reporting procedures may cause a delay in processing your claim.
Please continue on to the next page. As a reminder, failure to follow your employer’s workplace injury reporting procedures may cause a delay in processing your claim.

Company Employing Injured Worker*
Injured Worker's Email Address (or Supervisor's Email Address)*
Name of Injured Worker*
First Last
Primary Phone Number*
Is the primary phone number a mobile or landline?*
- Mobile
- Landline
Secondary Phone Number
Is the secondary phone number a mobile or landline?
- Mobile
- Landline
Social Security Number*
Injured Worker's Birthdate*
MM slash DD slash YYYY
Sex of Injured Worker*
Marital Status*
Number of Dependents*
Please list an Emergency Contact.
First Last Phone Number Relationship to You
Home Address*
Street Address Address Line 2 City State ZIP Code
Weekly (or Hourly) Wages
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Date of This Report*
MM slash DD slash YYYY

Date of Incident*
MM slash DD slash YYYY
Date Employee Reported Incident*
MM slash DD slash YYYY
Time of Incident

: Hours

Minutes

AM/PM
Time Employee Reported for Work Day of Incident

: Hours

Minutes

AM/PM
Person Employee Reported Incident To*
First Last
Client Where Incident Occurred (For staffing companies only)
Address Where Incident Occurred*
Street Address Address Line 2 City State ZIP Code

Describe the incident in detail (how, why, where, what)*
Type of Injury (cut, sprain, bruise, fracture, etc.)*
Which part of body injured (be specific)*
Are there any safety issues that contributed to this injury? Please detail
List all witnesses to this incident
List all prior injuries sustained at work and outside of work in the last 10 years that required medical attention (include dates, injuries, and body parts)
Consent*
By submitting this form, you agree that you are signing this form electronically and that all information you provided to InSource Employer Solutions / Business Insurers of Georgia is complete and accurate to the best of your knowledge. You agree your electronic signature (hereafter referred to as "E-Signature") is the legal equivalent of your manual signature. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature. You acknowledge your understanding that any person who knowingly submits false or fraudulent information is guilty of a crime and may be subject to fines and/or confinement in state prison.
Please Type Your Name*
First Last
Transcribed and/or translated by (if necessary)
First Last
Transcriber/Translator's Email Address
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For Internal Use Only (Routing)
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MTWR-D
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F-D
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WKND-D
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HOL-D

Employee's Report of Incident

Step 1 of 4

For Internal Use Only (Routing)