Home
Employers
Employee
Health
Internal Resources
Find A Job
About Us
COVID-19 Resources
Get In Touch
Menu
Home
Employers
Employee
Health
Internal Resources
Find A Job
About Us
COVID-19 Resources
Get In Touch
Submit A Claim
Submit A Claim
Read before submitting!
Avoid using Internet Explorer. Instead, use Chrome or Microsoft Edge. Double-check all fields for accuracy & Look for a "Success" confirmation after submitting.
×
Dismiss this alert.
Employee Name
Employee ID
Employment Start Date
Title of employee position
Shift
1st
2nd
3rd
N/A
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?
No
Yes
Corrective Actions
Body Part Injured
Injury reported on time?
No
Yes
If Reported Late, Why?
Pre-Existing Conditions?
No
Yes
If yes, what are they?
Was the employee wearing PPE at the time of the incident?
No
Yes
If yes, what PPE was the employee wearing?
If the employee was injured while lifting, select the weight. If not, skip this step.
N/A
5 lbs
10 lbs
15 lbs
20 lbs
25 lbs
30 lbs
35 lbs
40 lbs
45 lbs
50-74 lbs
75-99 lbs
100+ lbs
Pictures Taken?
No
Yes
Video Surveillance Available?
No
Yes
Witness Statement Available?
No
Yes
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:
SUBMIT