Claims

Report a workplace injury.

Send the details to E&A Insurance Group as soon as possible so we can help file the claim with your carrier.

Complete this form as soon as possible after a workplace injury. Leave any item blank if unknown, but do not delay reporting to gather every detail. Fields marked with * are required.

Getting started

Did or will the employee seek medical attention at a physician’s office, urgent care, or hospital? *

Did the employee miss any time from work? *

Did the injury or illness result in the employee’s death? *

Policy and incident

Injury or illness date *

Date reported to employer *

Incident city *

Incident state *

Incident ZIP code *

Reporting and contact details

Reporter, person filing this report *

Main contact at the business *

Contact email *

Contact phone *

Injured employee

Employee name *

Social Security number, last 4 digits only

For privacy, do not enter a full Social Security number.

Gender

Occupation or job title *

Is the injured worker an owner, partner, or officer of the company? *

Employee email

Employee date of birth

Employee date of hire

Employee primary phone

Employee home address

Employee city

Employee state

Employee ZIP code

Is the employee represented by an attorney? *

Did the injury happen on the employer’s premises? *

Injury details

Explain what happened *

Cause of injury *

For example: fall, slip, trip, cut, burn, strain, or struck by object.

Primarily affected body part *

Injury description *

For example: strain, laceration, fracture, or burn.

Did the injured employee already receive treatment? *

Do you expect that the injured employee will receive treatment? *

Missed time

Last day worked before lost time

Return-to-work date, if returned

Were they paid for the date of injury? *

Have they returned to work? *

Slip, trip, or fall claimsComplete this section only if it applies.

For a slip, trip, or fall claim, were photographs taken of the area?

Anything else we should know?

Additional comments

Include witnesses, supporting documents, safety measures taken, or any other relevant details.

Submitted by

Submitted by name *

Submitted by title *

Date *