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Back

• Claims Management
• Workers’ Comp Claims Services
• Risk Class Code Reclassification
• L&I & UBI Account Resolution

• L&I’s Return to Work Program
• Penalty & Interest Negotiation
• Master Bus. Application Completion
• Claims Investigation

• Research Prior to Acquisition

Back

• Human Resources
• Employment Law
• Private Investigation

• Vocational Counseling

Back

• Safety
• Safety Services
• Safety Ambassador Program

• Safety Videos
• Safety Projects
• Safety Library

• Safety Apps
• Safety Links
• Monthly Safety Packets

Back

• Resources
• Fillable Claim Forms
• Members Online Claim Forms
• RISE Up Program
• Webinars

Member Login Report a Claim » Return to Home »

Report A Claim

Please report a claim to RS by sending the Employer Report of Accident form to [email protected].

We will notify members when the updated forms have been loaded onto our new website.  Thank you.

"*" indicates required fields

Employer Report of Industrial Injury or Occupational Disease

Name of person completing this form*

First Last

Title of person completing this form*

Claim Number*

Employee Name*

First Last

Employee's Job Title*

Employee's LAST FOUR of SSN*

Name of Business*

Business Phone Number*

Business Mailing Address*

Business Location

Same as Mailing Address

Business Location Address

UBI

L&I Account ID #

Employee's Risk Class Code

Describe in detail how the incident occurred*

Was this incident caused by failure of a machine or product OR someone who is not an employee?*

Yes

No

Possibly

Do you question the validity of this claim?*

Yes

No

Date of injury or last occupational exposure

Date Reported to Employer

Time Reported to Employer

Body part(s) injured or exposed – include side of body*

Employer comments or concerns about this claim:*

Were you contributing to this worker and/or family’s health care benefits (medical, dental, and/or vision insurance) on the date of injury?*

Yes

No

Date medical, dental and vision coverage ends:

How much did you pay for medical, dental and vision coverage? (list amount)*

Select One*

Per Hour

Per Day

Per Week

Per Month

Other

Rate of Pay*

Select One*

Per Hour

Per Day

Per Week

Per Month

Other

Hours per Day*

Days per Week*

Average daily earnings (list amount)*

Source of average daily earnings

Tips, Commissions, Piecework or other

All bonuses paid 12 months prior to injury?

Did the employee miss any time from work?*

Yes

No

Missed work starting on*

Returned to work on

Do you pay wages/salary if the employee is off work?*

Yes

No

Type of Pay*

Regular Wages / Salary

Paid Time Off

Vacation

Sick

Contractual

Other

Did the employee die?*

Yes

No

Has the job of injury been modified to accommodate restrictions from the Activity Prescription Form?*

Yes

No

N/A

Is temporary light duty work available during recovery?*

Yes

No

N/A

Contact for light duty return to work information for the employee?*

First Last

Phone #

Email*

Any Witnesses?*

None

One Witness

Two Witnesses

Three Witnesses

Witness #1*

First Last

Phone #

Email

Witness #2*

First Last

Phone #

Email

Witness #3*

First Last

Phone #

Email

Date Signed*

Agree and Confirm

I declare these statements to be true to the best of my knowledge and belief and I understand and consent to the use of the digital signature above, for the purpose of processing this form.

Are you human?

Email

This field is for validation purposes and should be left unchanged.

Employer Claim Report

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