Injury Declaration Form

Injury Declaration Form
Please complete this form if you have experienced an injury.
Personal Information
Full Name
First NameLast Name
Date of Birth
MonthDayYear
Date
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Injury Details
Date of Injury
MonthDayYear
Date
Location of Injury
Description of Injury
Did the injury occur at work?
YesNo
Was the injury reported to a supervisor?
YesNo
Medical Treatment
Have you sought medical treatment for this injury?
YesNo
Name of Medical Provider
Date of Medical Treatment
MonthDayYear
Date
Description of Medical Treatment
Attachments
If you have any medical reports or documents related to the injury, please upload them here.
Medical Reports
Cancelof
Other Documents
Cancelof
Declaration
Should be Empty: