Workers' Compensation Injury/Accident Claim or Report

Please select carefully:

CLAIM - Request for medical treatment
REPORT - No medical treatment requested

Please provide the following information ( Press TAB to move from field to field):

Please provide information about the injured employee:

INJURED PANTHERID:
FIRST NAME:
MI:
LAST NAME:
E-MAIL:
DEPARTMENT:
WORK SCHEDULE:
PHONE:
ACCIDENT DATE:
TIME OF ACCIDENT:
DATE REPORTED:
REPORTED BY:
ACC. PLACE(BLDG):
Please be very specific
SUPERVISOR NAME:
SUPERVISOR PHONE:
SUPERVISOR EMAIL:

SUPERVISOR NOTIFIED ?

Yes No

DATE:



NOTIFICATION TIME:




PART BODY OF AFFECTED:


TYPE OF INJURY:
(e.g. bruise, cut, etc.
)

CAUSE(S) OF INJURY:


DESCRIPTION OF THE ACCIDENT: ( In up to 255 characters how did the accident/injury occur?)
 

IS THIS A CLAIM?

      Yes. A medical appointment is requested.
      Yes. This was a medical emergency. The employee was transported to the medical facility below:
The doctor/ medical facility was:


IS THIS A REPORT FOR DOCUMENTATION ONLY?
      Yes, medical treatment is NOT required. (First Aid Given)
      Yes, medical treatment is NOT required. (No First Aid Given)


Please be advised: Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company or self-insured program or files a statement of claim containing any false or misleading information is guilty of a felony of the third degree. Florida Statute 817.234 (1) (b)

I acknowledge and understand the previous statement above.
Injured worker and supervisor agree to participate in the Worker`s Compensation Return-To-Work Program.

For Questions Please Call Worker`s Compensation Assistant at: (305) 348-7960


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