Employee Statement of Injury or Illness

The tools you need.

Employee statement of injury or illness.

Documenting when an employee gets hurt or sick on the job.

Employee Statement of Injury or Illness.

Documenting an employee’s injury or illness.

Employer (Company Name)*
Employer State
Email Address of Person Completing Form (employee)*
Enter Email Confirm Email
Employee Information
Name*
First Last
Address
Street Address Address Line 2 City ZIP / Postal Code
Phone Number (Home)*
Phone Number (Other)*
Job Title*
Department*
Work Shift
Did the injury occur on the employer premises?
Date of Accident
Normal Shift Start Time
Time of Accident
Worked Until End of Shift
Accident was Reported To:
Description of Injury*
Part of Body
Please Describe the Injured Body Part(s)*
Attachment (attach document if needed)
Max. file size: 300 MB.
eSign This Form

I hereby declare that the statements provided in this document are; to the best of my knowledge and belief, complete and true. Fraud Notice: Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of the law and may also be subject to criminal and civil penalties. Note: By typing my name below I am electronically signing this form.
eDate This Form
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.
This field is for validation purposes and should be left unchanged.

Any Questions? Call 724-864-8745 Or, Contact Us

About East Coast Risk Management

We’re a mid-sized consulting firm specializing in the areas of safety consulting, human resources consulting and claims management.

We have eleven office locations to serve you in Pennsylvania, Georgia, Ohio, Tennessee, Illinois and North Carolina.

Our Business Philosophy
The entire business process and culture of our clients is taken into consideration, to maximize the impact on the client’s bottom line.

East Coast Risk Management – Corporate Office

7562 State Route 30
North Huntingdon, PA 15642

Call 724-864-8745
Fax 724-864-9265
info@eastcoastrm.com

Employee Statement of Injury or Illness

The tools you need.