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Employer Business Name
*
Employer Contact Name
*
Employer Contact Phone
*
Accendent State
State Where Accident Occurred
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California
Colorado
Connecticut
Delaware
Florida
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Idaho
Illinois
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Injured Worker's First Name
Injured Employee's Last Name
Employee Phone Number
Date of Injury
Additional information (optional)
Next
Insured Worker's Date of Birth
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1921
1920
Injured Worker's Social Security Number
Injured Worker's Email
Injured Worker's Street Address
Injured Worker's City Address
Mailing State
Injured Worker's State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Injured Worker's Zip Code
How much work has the employee missed?
How much work has the employee missed?
3 days or fewer
More than 3 days
Additional information (optional)
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Safety Library
English Version
Abrasive Wheel Tools
Accident Prevention
Aerial Lifts
Africanized Honey Bees
Arc Welding
Asphalt Safety
Automobile Repair Shops
Bloodborne Pathogens
Carbon Monoxide
Chain Saw Safety
Combustible Dust
Crane Safety
Developing a Safety Plan
Electrical Safety
Emergency Planning
Ergonomics
Extension Cord Safety
Fall Prevention
Farm Equipment Safety
Floor and Walkway Safety
Forklifts
Fundamentals of First Aid and AEDs
Grain Handling
Ground Fault Circuit Interrupters (GFCIs)
Guardrails
Hazard Communication
Hazard Evaluations
Heavy Equipment Safety
Industrial Slings
Ladder Safety
Laser Safety
Lead Safety
Lockout / Tagout Procedures
Machine Guarding
Material Handling
Meat Slicers and Grinders
Motor Vehicle Safety
Nail Gun Safety
Nail Salons
Noise Safety
Overhead Power Lines
Personal Protective Equipment
Personal Protective Equipment, Body and Torso
Personal Protective Equipment, Eyes
Personal Protective Equipment, Foot and Leg
Personal Protective Equipment, Hand and Arm
Personal Protective Equipment, Head
Personal Protective Equipment, Respirators
Pneumatic Tool Safety
Poisonous Plants
Portable Fire Extinguishers
Powder-Actuated Tools
Power Press Brake Safety
Power Tools
Preventing Workplace Burns
Proper Lifting Techniques
Proper Scaffold Use
Proper Use of Cleaning Chemicals
Protecting Workers from Sun Exposure
Radiation
Restaurant Safety
Road Construction
Roof Maintenance
Roofing Safety
Security and Theft Prevention
Severe Weather and Natural Disasters
Stinging Insects
Storing Materials
Stress Management
Supported Scaffolds
Suspended Scaffolds
Temperature Extremes - Cold
Temperature Extremes - Heat
The Importance of a Clean Workplace
Ticks and Mosquitoes
Tree Trimming Safety
Trench Safety
Venomous Arachnids
Venomous Snakes
Woodworking Safety
Workplace Fire Safety Equipment
Spanish Version
Abrasive Wheel Tools (Español)
Accident Prevention (Español)
Aerial Lifts (Español)
Africanized Honey Bees (Español)
Arc Welding (Español)
Asphalt Safety (Español)
Automobile Repair Shops (Español)
Bloodborne Pathogens (Español)
Carbon Monoxide (Español)
Chain Saw Safety (Español)
Combustible Dust (Español)
Crane Safety (Español)
Developing a Safety Plan (Español)
Electrical Safety (Español)
Emergency Planning (Español)
Ergonomics (Español)
Extension Cord Safety (Español)
Fall Prevention (Español)
Farm Equipment Safety (Español)
Floor and Walkway Safety (Español)
Forklifts (Español)
Fundamentals of First Aid and AEDs (Español)
Grain Handling (Español)
Ground Fault Circuit Interrupters (GFCIs) (Español)
Guardrails (Español)
Hazard Communication (Español)
Hazard Evaluations (Español)
Heavy Equipment Safety (Español)
Industrial Slings (Español)
Ladder Safety (Español)
Laser Safety (Español)
Lead Safety (Español)
Lockout / Tagout Procedures (Español)
Machine Guarding (Español)
Material Handling (Español)
Meat Slicers and Grinders (Español)
Motor Vehicle Safety (Español)
Nail Gun Safety (Español)
Nail Salons (Español)
Noise Safety (Español)
Overhead Power Lines (Español)
Personal Protective Equipment (Español)
Personal Protective Equipment, Body and Torso (Español)
Personal Protective Equipment, Eyes (Español)
Personal Protective Equipment, Foot and Leg (Español)
Personal Protective Equipment, Hand and Arm (Español)
Personal Protective Equipment, Head (Español)
Personal Protective Equipment, Respirators (Español)
Pneumatic Tool Safety (Español)
Poisonous Plants (Español)
Portable Fire Extinguishers (Español)
Powder-Actuated Tools (Español)
Power Press Brake Safety (Español)
Power Tools (Español)
Preventing Workplace Burns (Español)
Proper Lifting Techniques (Español)
Proper Scaffold Use (Español)
Proper Use of Cleaning Chemicals (Español)
Protecting Workers from Sun Exposure (Español)
Radiation (Español)
Restaurant Safety (Español)
Road Construction (Español)
Roof Maintenance (Español)
Roofing Safety (Español)
Security and Theft Prevention (Español)
Severe Weather and Natural Disasters (Español)
Stinging Insects (Español)
Storing Materials (Español)
Stress Management (Español)
Supported Scaffolds (Español)
Suspended Scaffolds (Español)
Temperature Extremes - Cold (Español)
Temperature Extremes - Heat (Español)
The Importance of a Clean Workplace (Español)
Ticks and Mosquitoes (Español)
Tree Trimming Safety (Español)
Trench Safety (Español)
Venomous Arachnids (Español)
Venomous Snakes (Español)
Woodworking Safety (Español)
Workplace Fire Safety Equipment (Español)