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Workers Compensation – Part 2 – Incident Info

Step 1 of 2

Date and Time:

Employer's Name:

First Last

Employer's Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Description of incident in which injury was sustained:

Time disabled (unable to work):

Date on which you returned to work:

List any work restrictions as a result of your work injury:

Did you report your injury?

To whom?

How did you report?

Written

Verbally

Telephone

On what date did you report the injury: