Submit A Claim

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Employee Name

Employee ID

Employment Start Date

Title of employee position

Shift

What time did you start your shift?

What PriorityWorkforce Branch services this employee?

Name of person submitting the claim

Details of Incident

Date of Incident

Time of Incident

Client Name and Location of Incident

Line Number / Department

On-site Contact

Name of Supervisor

Work Related?

Corrective Actions

Body Part Injured

Injury reported on time?

If Reported Late, Why?

Pre-Existing Conditions?

If yes, what are they?

Was the employee wearing PPE at the time of the incident?

If yes, what PPE was the employee wearing?

If the employee was injured while lifting, select the weight. If not, skip this step.

Pictures Taken?

Video Surveillance Available?

Witness Statement Available?

Conservative Care Provided?

Yes No

Medical Attention At Clinic Needed?

Yes No

Taken to Hospital by Medical Transportation (Such as Ambulance)

Yes No

If the employee was taken to the Hospital, name the Hospital below: