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NOTIFICATION OF INJURY This Notification of Injury Form is to be used for accident medical claims. This form and all other correspondence must be submitted within 90 days from the date of accident.

How to fill out this notification of injury

How to Fill out this Notification of Injury:

1. Start by filling in your personal information, such as your name, address, phone number, and email.
2. Provide the details of the injury, including the date and time it occurred, the location, and a description of what happened.
3. Indicate whether the injury occurred on the job or outside of work.
4. If the injury happened at work, provide your job title and department.
5. Specify the type of injury sustained, whether it is physical, psychological, or both.
6. If medical treatment was sought, include the name of the healthcare provider or hospital visited.
7. Describe any immediate actions taken after the injury, such as informing a supervisor or seeking immediate medical attention.
8. Attach any supporting documents or evidence related to the injury, such as medical reports or witness statements.
9. Sign and date the notification form to confirm its accuracy.

Who needs this Notification of Injury:

1. Employees who have suffered an injury can use this form to report the incident to their employer.
2. Employers require this notification of injury to ensure that proper procedures are followed, including providing necessary medical treatment and addressing any potential workplace hazards.
3. Insurance companies may also need this form to process any related claims and determine compensation or benefits.

For pdfFiller’s FAQs

What is this notification of injury?

This notification of injury is a formal document that must be completed to report a work-related injury or illness.

Who is required to file this notification of injury?

Employers are required to file this notification of injury when an employee suffers a work-related injury or illness.

How to fill out this notification of injury?

The notification of injury should be filled out completely and accurately, including details of the injury or illness, the date and time it occurred, and any medical treatment received.

What is the purpose of this notification of injury?

The purpose of this notification is to document the work-related injury or illness, ensure that the employee receives appropriate medical care and benefits, and to prevent future incidents.

What information must be reported on this notification of injury?

The notification should include details such as the employee's name, date of birth, contact information, date and time of injury, description of the injury, and any medical treatment received.

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