Get Injury-illness Report Form - Hmsa.com

Completing the Injury-Illness Report Form online is an essential step for reporting any incidents that may have affected your health or well-being. This guide provides clear, step-by-step instructions to help you navigate the form with ease.

Follow the steps to accurately fill out the Injury-Illness Report Form.

1. Press the ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section I, start by providing general information. Enter the name of the HMSA member or dependent who is injured or ill, followed by the date of the incident. Specify the location where the incident occurred, selecting from the provided options: work, home, or other.
3. Detail how the accident occurred in the designated space, and provide a diagnosis or brief description of the injury or illness. It's also important to include your contact information, both at work and home.
4. Indicate whether you have hired or plan to hire an attorney by selecting 'Yes' or 'No'. If 'Yes', please provide the name and contact information for your attorney.
5. If your accident is work-related, proceed to Section II. Here, confirm whether you have filed a Workers' Compensation claim. If 'Yes', provide the status of your claim and details about your employer and their insurance.
6. If your injury involved a motor vehicle, complete Section III. State whether you were a passenger, driver, or pedestrian and provide the necessary details about the vehicle involved, the owner, and the insurance information.
7. In Section IV, indicate if you believe another party may be responsible for your injury or illness. Provide their details, as well as information on any claims or demands made against them.
8. Once all sections are accurately completed, review the form thoroughly for any errors or missing information. Then, proceed to save the changes, and download, print, or share the form as needed.

Start filling out your Injury-Illness Report Form online today for efficient documentation and processing.