Get And Sign First Injury Report Form

Accident Date of injury Location where accident occurred Hour of injury a*m* Date injury or illness reported If fatal give date of death p*m* If fatal give marital status Single Injured Worker Name of Injured Worker Phone Number Divorced Married If fatal give number of dependent children Widowed Type of ID Social Security No* Employment Visa Green Card Passport No* Unknown Occupation at time of injury or illness Date of birth Sex Male Female Nature and Cause of Accident Machine tool or object...