Get Accident Report

Filing an accident report is a crucial step in documenting workplace incidents and ensuring that employees receive appropriate benefits. This guide will provide you with a clear, step-by-step approach to filling out the Accident Report online, making the process straightforward and efficient.

Follow the steps to complete your Accident Report accurately and efficiently.

1. Click the ‘Get Form’ button to access the Accident Report, which will open in your online editor.
2. Begin by filling out section 1, which requests the federal employer's identification number. This is a unique number assigned to businesses by the IRS for tax purposes.
3. In section 2, provide the name of the employer and their telephone number. Ensure that both pieces of information are accurate.
4. Section 3 requires the mailing address of the employer. Be sure to use the correct format for street address, city, state, and ZIP code.
5. If the location of the accident differs from the mailing address, fill out section 4 with the appropriate details.
6. Describe the nature of the employer's business in section 5. This information helps classify the industry.
7. In section 6, enter the employee's name, age, and sex. These details are necessary for identifying the injured party.
8. Fill out the employee's home address in section 7, which should also include the full street address, city, state, and ZIP code.
9. Section 8 asks for the employee's social security number, date of birth, home phone number, and occupation. Enter this information carefully.
10. Provide the date and time of the injury in section 9, making sure to specify whether it occurred in the A.M. or P.M.
11. In section 10, describe the place of the accident or last exposure, including city and county.
12. For section 11, indicate whether the accident occurred on the employer's premises by choosing 'Yes' or 'No'.
13. Section 12 requests details on how the accident occurred. Provide a concise description of the events leading to the injury.
14. Explain what the employee was doing when the injury happened in section 13. Be as specific as possible.
15. In section 14, name the substance or object directly responsible for the injury.
16. Describe the nature and extent of the injuries in section 15, mentioning any specific body parts involved.
17. For section 16, indicate if the worker was admitted to the hospital and provide the hospital name and address if applicable.
18. Section 17 asks for the name and address of the attending physician or clinic. Provide accurate details.
19. In section 18, clarify whether the employee has returned to regular duty.
20. Specify in section 19 if compensation is being paid, and provide additional details as required.
21. Section 20 requires the weekly compensation rate to be filled in.
22. Indicate in section 21 whether the employee died as a consequence of the accident and provide the date if applicable.
23. If the employee has dependents, fill out section 22 with their names and addresses.
24. Complete section 23 by providing the insurance carrier and third-party administrator information.
25. In section 24, fill out the date of the report, your name, and your title.
26. After reviewing all sections for accuracy, you can save your changes, download a copy, print the form, or share it as needed.

Complete your Accident Report online today to ensure timely processing and benefit access.