MGI-INCIDENT REPORT- First Response

• Conducted on

  Date

• Prepared by

• Location
  Address

• This Injury and Illness Incident Report is one of the first forms you must fill out when a recordable work-related injury or illness has occurred.

• **IMPORTANT** PLEASE SUBMIT THIS FORM WITHIN 24 HOURS OF INJURY.
  mail: Injuryreports@moralesgroup.net
  mail: claimsexpress@unitedheartland.com
  Phone : 0000 000 000

CLIENT INFORMATION

• Client:

  Select Accion Performance Address: 8161 Zionsville Rd Indianapolis Indiana Code: ACCION Advanced Distribution Address: 8019 Allison Avenue Indianapolis Indiana Code: ADVDISTR AEL SPAN Address: 6712 Grade Lane #509 Louisville Kentucky Code: AELS AEF Construction, LLC. Address: 14032 Britton Park Rd. Fishers Indiana Code: AETNA Alom Technologies Address: 2670 Executive Dr Ste B Indianapolis Indiana Code: ALOM King Systems Address: 15011 Herriman Blvd. Noblesville Indiana Code: AMBU Arrow Container Address: 2900 Shadeland Ave Indianapolis Indiana Code: ARROW Arvco Container Corp. Address: 8219 Northwest Blvd, Ste 150 Indianapolis Indiana Code: ARVCO Automatic Distributors Address: 5111 W. 76th St. Indianapolis Indiana Code: AUTDIS Automatic Pool Covers Address: 17397 Oak Ridge Road Westfield Indiana Code: AUTPOO Beacon Industries Address: 912 S Walnut St Edinburgh Indiana Code: BEACON Kelly Services Address: 5355 W. 76th St. Indianapolis Indiana Code: BECKCOULT Belkin/Accion Address: 558 Airtech Parkway Plainfield Indiana Code: BELKIN Bloemer Food Sales Address: 925 S 7th Street Louisville Kentucky Code: BLOEMER Brightview Landscapes, LLC Address: 5635 Progress St Indianapolis Indiana Code: BVL Caito Food Service Inc. Address: 3120 North Post Road Indianapolis Indiana Code: CAIT Caltherm, Inc. Address: 910 S. Gladstone Ave. Columbus Indiana Code: CALTH Carter Lumber Company Address: 2901 N Morton Street Franklin Indiana Code: CARTER Catheter Research, Inc Address: 6102 Victory Way Indianapolis Indiana Code: CATH Ceva Logistics Park 100 Address: 7365 Winton Drive Indianapolis Indiana Code: CEVA Cintas Uniform Services Address: 7258 Georgetown Road Indianapolis Indiana Code: CINTAS CloudBlue Technologies, Inc. Address: 5345 Decatur Blvd, Suite A Indianapolis Indiana Code: CLOUDBLUE CloudBlue Tech., Inc. Address: 1135 Aviation Rd. Hebron Kentucky Code: CLOUDBLUE-KY Columbus Container, Inc. Address: 3460 Commerce Dr. Columbus Indiana Code: COLCONT CPS, Inc. Address: 5648 West 82nd St Indianapolis Indiana Code: CPS Cross Road Centers / Accion Address: 8192 Allison Ave Indianapolis Indiana Code: CRC Crust 'N More Inc Address: 10516 Folsom Dr Indianapolis Indiana Code: CRUST Decatur Plastic Products, Inc Address: 3250 N State Highway 7 North Vernon Indiana Code: DECAT Depco Address: 11827 Greenfield Avenue Noblesville Indiana Code: DEPCO Derby Supply Chain Solutions Address: 4301 W 73 st Anderson Indiana Code: DERBY Direct Shot Distributing, LLC. Address: 2001 Commerce Pkwy Franklin Indiana Code: DSD Eagle Battery, LLC. Address: 3720 South Hoyt Ave. Muncie Indiana Code: EAGLE EnterMarket / Accion Address: 7901 W 21st Street, Ste 1X Indianapolis Indiana Code: ENTER Facade Tek Address: 5110 West 76th Street Indianapolis Indiana Code: FACADE Facility Concepts, Inc. Address: 7676 Zionsville Rd. Indianapolis Indiana Code: FACCONC Facility Concepts - Peru Address: 801 N Clay Street Peru Indiana Code: FACPERU Facility Concepts - Whitestown Address: 4881 Perry Worth Rd Whitestown Indiana Code: FACWHITE Finish Line Address: 3308 N. Mitthoeffer Indianapolis Indiana Code: FINLINE Flambeau Products, Inc. Address: 4325 Middle Road Columbus Indiana Code: FLAMBPRO Forest Products Supply CO. Address: 310 S. Kitley Ave. Indianapolis Indiana Code: FOREST FullBeauty Brands Address: 2300 Southeastern Avenue Indianapolis Indiana Code: FULLBEAUTY Garden Cuts Address: 4501 Massachusetts Ave Indianapolis Indiana Code: GARDEN Gared Sports Address: 9200 E 146th St Ste A Noblesville Indiana Code: GARED George Utz, Inc. Address: 14000 N 250 W Edinburgh Indiana Code: GEO UTZ Glasrite Address: 6790 E 32nd St Indianapolis Indiana Code: GLAS GNC Address: 4055 S 500 E Bldg 7A Whitestown Indiana Code: GNC Goodyear Wholesale Address: 5850 S. Kopetsky Drive, Unit A Indianapolis Indiana Code: GOODYR Great Dane Limited Partnership Address: 2664 E US Hwy 40 East Brazil Indiana Code: GRDANE Harlan Bakeries / Avon Address: 7597 East US Highway36 Avon Indiana Code: HARAV Harlan Bakeries / Gtwn North Address: 7575 Georgetown Road Indianapolis Indiana Code: HARGT Henry Schein Address: 5315 West 74th Street, Suite 100 Indianapolis Indiana Code: HENSCH Herff Jones Address: 4601 W 62nd Street Indianapolis Indiana Code: HERFF Heartland Food Producers Address: 14300 Clay Terrace Blvd. Suite 249 Carmel Indiana Code: HFP Hisada America Address: 1191 S Walnut St Edinburg Indiana Code: HISADA Hittle Landscape, Inc. Address: 17778 Sun Park Drive Westfield Indiana Code: HITTLE Pro Unlimited Address: 2700 N. Richardt Avenue Indianapolis Indiana Code: HOUGHTON Harding Poorman Group Address: 4923 West 78th Street Indianapolis Indiana Code: HPG IDS Address: 9431 All Points Parkway Plainfield Indiana Code: IDS Ingram Micro Mobility Address: 501 Airtech Parkway Plainfield Indiana Code: IMMI Ingram Micro Mobility - ITAD Address: 5345 Decatur Blvd, Suite A Indianapolis Indiana Code: IMMIITAD BrightPoint Services, LLC. Address: 6001 Global Distribution Way Louisville Kentucky Code: IMMI-KY Ingram Micro Mobility JDC Metro Address: 250 Hilton Lane Jeffersonville Indiana Code: IMMIJEFF Indianapolis Fruit Company, Inc. Address: 4501 Massachusetts Ave. Indianapolis Indiana Code: INDFRUIT Insultech Address: 5730 Dividend Rd Indianapolis Indiana Code: INSULTECH International Packaging & Specialties Address: 1414 West St Indianapolis Indiana Code: INTERPNS Irsay Estate Address: 1711 W. 116th Street Carmel Indiana Code: IRSEST Kid Glove Service, LLC. Address: 2525 N. Shadeland Ave. Indianapolis Indiana Code: KID King Systems Address: 15011 Herriman Blvd. Noblesville Indiana Code: KING Langham Address: Indiana Code: LANG Lids Address: 5304 W. 74th St. Indianapolis Indiana Code: LID LSC Communications Address: 5550 W. 74th Street Indianapolis Indiana Code: LSC Lysse Industries, LLC Address: 8460 Bearing Drive Indianapolis Indiana Code: LYSSE Mansfield-King, LLC Address: 6501 Julian Ave Indianapolis Indiana Code: MANSF Mariah Foods Address: 1333 Indiana Ave. Columbus Indiana Code: MARH Max Katz Bag Co., Inc. Address: 235 South LaSalle Street Indianapolis Indiana Code: MAX Merchandise Warehouse Co., Inc Address: 1414 S West Street Indianapolis Indiana Code: MERCH Mervis Industries, Inc. Address: 6550 E. 30th St, Ste 151 Indianapolis Indiana Code: MERVIS Meyer Plastics Address: 5167 East 65th Street Indianapolis Indiana Code: MEYER Morales Group Inc Address: 5628 W 74th Street Indianapolis Indiana Code: MGI Micrometl Corp Address: 3035 N Shadeland Ave Indianapolis Indiana Code: MICRO Monarch Beverage Company Address: 9347 Pendleton Pike Indianapolis Indiana Code: MONARCH Moriden America Address: 9760 Mayflower Park Dr, Ste 100 Carmel Indiana Code: MORIDEN Multi Packaging Solutions / Accion Address: 2020 Production Dr Indianapolis Indiana Code: MPS Neill-LaVielle Supply Address: 1711 S. Floyd St. Louisville Kentucky Code: NEILL Newell Brands Address: 9999 East 121st St Fishers Indiana Code: NEWBRA Network Global Logistics Address: 250 S Kitley Ave Indianapolis Indiana Code: NGL NHK Seating of America, Inc Address: 2298 West State Road 28 Frankfort Indiana Code: NHK Nikkei MC Aluminum Co Address: 6875 South Inwood Drive Columbus Indiana Code: NIKKEI Nitto Denko Address: 8119 Zionsville Rd Indianapolis Indiana Code: NITDEN Neovia Logistics / Accion Address: 5151 W 76th St Indianapolis Indiana Code: NLA Neovia / Greenwood Address: 850 N Graham Rd Greenwood Indiana Code: NVG Package Right LLC Address: 811 Development Dr. Tipton Indiana Code: PACKRIGHT Patriot Porcelain Address: 2500 N. Union St. Kokomo Indiana Code: PATRIOT Peer Foods, Inc Address: 1825 Stout Field Terrace Indianapolis Indiana Code: PEER Ferr Foods Group, Inc Address: 1999 Indiana Ave Columbus Indiana Code: PEERC Piazza Produce, Inc Address: 5941 W 82nd Street Indianapolis Indiana Code: PIAZZA Plastic Recyling Inc Address: 2015 S Pennsylvania St Indianapolis Indiana Code: PLAREC Precision Propeller Industries, Inc. Address: 2427 N. Ritter Ave Indianapolis Indiana Code: PPI Practrical Property Group Address: 17925 Sun Park Drive Westfield Indiana Code: PRACTICAL Pratt Corporation Address: 3035 N Shadelend Ave Indianapolis Indiana Code: PRAT Prime Distribution Services, Inc. Address: 9955 AllPoints Pkwy. Plainfield Indiana Code: PRIME Print Resources Address: 1500 E Riverside Dr Indianapolis Indiana Code: PRINT Priority Press, Inc. Address: 4026 W. 10th St. Indianapolis Indiana Code: PRIORITY Pro Unlimited Address: 2700 N. Richardt Avenue Indianapolis Indiana Code: PRO Pitney Bowes Park 100 Address: 15011 Herriman Blvd Noblesville Indiana Code: PSI Pitney Bowes Whitestown Address: 5940 Industrial Court Indianapolis Indiana Code: PSIWHT Polymertech PTS / Accion Address: 7736 Zionsville Road Indianapolis Indiana Code: PTS Pyramid Paper Products Address: 725 S Mapleton St Columbus Indiana Code: PYR Red Gold Inc. Address: PO Box 83 Elwood Indiana Code: REDG Reflex Allen Address: 2655 Fortune Cir W Ste A Indianapolis Indiana Code: REFLEX Rivar's Inc. Address: 9900 Westpoint Drive, Suite 132 Indianapolis Indiana Code: RIVA RMIS Location Address: Code: RMIS RR Donnelley Address: 5550 W. 74th Street Indianapolis Indiana Code: RRDONN Ryder Conagra Address: 640 S State Road 39 Lebanon Indiana Code: RYDCON Ryder Logistics Address: 9101 Orly Road Indianapolis Indiana Code: RYDPEP Ryder Pitney Bowes Address: 5490 Industrial Court, Ste 100 Whitestown Indiana Code: RYDPIT Ryder Whirlpool P1 Address: 2801 Airwest Blvd. Plainfield Indiana Code: RYDWHI Ryder Xerox Address: 760 Commerce Parkway Greenwood Indiana Code: RYDXER Sacoma International, Inc. Address: 955 S. Walnut St. Edinburg Indiana Code: SAC Salsbery Brothers Landscaping Address: 4317 E 146th Street Carmel Indiana Code: SALSBERY Schenker, Inc. Address: 6555 E. 30th Street Indianapolis Indiana Code: SCHEN SGI Address: 8350 Allison Ave Indianapolis Indiana Code: SGI Shenandoah Growers Address: 4001 West Minnesota Street, Suite 200 Indianapolis Indiana Code: SHEN Shenandoah Special Projects Address: 4001 W Minnesota Street Indianapolis Indiana Code: SHENANDOAH Spartan Warehouse & Distribution Company Address: 3333 Mesilla Ct. Indianapolis Indiana Code: SPART S & S Steel Address: 444 East 29th Street Anderson Indiana Code: SSSTE Staffmark / Home Depot Address: 1390 S. Perry Road Plainfield Indiana Code: STAFF-HD OHL Contract Logistics / Accion Address: 1100 Whitaker Rd. Plainfield Indiana Code: STAFF-OHL Stanly Black and Decker Address: 501 W New Road Greenfield Indiana Code: STANLEYB Stratosphere Quality, LLC Address: 12024 Exit 5 Parkway Fishers Indiana Code: STRATOS Sunright America, Inc. Address: 6205 South International Drive Columbus Indiana Code: SUNRIGHT Superior Metal Technologies LLC Address: 9850 E. 30th St. Indianapolis Indiana Code: SUPMETAL Sur La Table Address: 901 E Northfield Drive Brownsburg Indiana Code: SURLA Telamon Corp Address: 1000 E 116th St Carmel Indiana Code: TELAMON Tempur Sealy International, Inc Address: 1000 Tempur Way Lexington Kentucky Code: TEMPUR Enbi Indiana, Inc. Address: 1703 McCall Drive Shelbyville Indiana Code: TENCATE Thermal Structures, Inc. Address: 2800 Airwest Blvd Plainfield Indiana Code: THER Tridien Medical Address: 9901 Kincaid Drive, Suite 200 Fishers Indiana Code: TRIDIEN Trinity Metals LLC Address: 6400 English Avenue Indianapolis Indiana Code: TRINITY United Hospital Services, LLC. Address: 9948 Park Davis Dr. Indianapolis Indiana Code: UNIHOSP Venture Logistics Address: 7901 W. 21st St. Indianapolis Indiana Code: VENTURE Volt/Stericycle Address: 6026 Lakeside Blvd Indianapolis Indiana Code: VOLSTE Westcon Group, Inc Address: 595 Perry Road Plainfield Indiana Code: WESTCON

  • Accion Performance Address: 8161 Zionsville Rd Indianapolis Indiana Code: ACCION
  • Advanced Distribution Address: 8019 Allison Avenue Indianapolis Indiana Code: ADVDISTR
  • AEL SPAN Address: 6712 Grade Lane #509 Louisville Kentucky Code: AELS
  • AEF Construction, LLC. Address: 14032 Britton Park Rd. Fishers Indiana Code: AETNA
  • Alom Technologies Address: 2670 Executive Dr Ste B Indianapolis Indiana Code: ALOM
  • King Systems Address: 15011 Herriman Blvd. Noblesville Indiana Code: AMBU
  • Arrow Container Address: 2900 Shadeland Ave Indianapolis Indiana Code: ARROW
  • Arvco Container Corp. Address: 8219 Northwest Blvd, Ste 150 Indianapolis Indiana Code: ARVCO
  • Automatic Distributors Address: 5111 W. 76th St. Indianapolis Indiana Code: AUTDIS
  • Automatic Pool Covers Address: 17397 Oak Ridge Road Westfield Indiana Code: AUTPOO
  • Beacon Industries Address: 912 S Walnut St Edinburgh Indiana Code: BEACON
  • Kelly Services Address: 5355 W. 76th St. Indianapolis Indiana Code: BECKCOULT
  • Belkin/Accion Address: 558 Airtech Parkway Plainfield Indiana Code: BELKIN
  • Bloemer Food Sales Address: 925 S 7th Street Louisville Kentucky Code: BLOEMER
  • Brightview Landscapes, LLC Address: 5635 Progress St Indianapolis Indiana Code: BVL
  • Caito Food Service Inc. Address: 3120 North Post Road Indianapolis Indiana Code: CAIT
  • Caltherm, Inc. Address: 910 S. Gladstone Ave. Columbus Indiana Code: CALTH
  • Carter Lumber Company Address: 2901 N Morton Street Franklin Indiana Code: CARTER
  • Catheter Research, Inc Address: 6102 Victory Way Indianapolis Indiana Code: CATH
  • Ceva Logistics Park 100 Address: 7365 Winton Drive Indianapolis Indiana Code: CEVA
  • Cintas Uniform Services Address: 7258 Georgetown Road Indianapolis Indiana Code: CINTAS
  • CloudBlue Technologies, Inc. Address: 5345 Decatur Blvd, Suite A Indianapolis Indiana Code: CLOUDBLUE
  • CloudBlue Tech., Inc. Address: 1135 Aviation Rd. Hebron Kentucky Code: CLOUDBLUE-KY
  • Columbus Container, Inc. Address: 3460 Commerce Dr. Columbus Indiana Code: COLCONT
  • CPS, Inc. Address: 5648 West 82nd St Indianapolis Indiana Code: CPS
  • Cross Road Centers / Accion Address: 8192 Allison Ave Indianapolis Indiana Code: CRC
  • Crust 'N More Inc Address: 10516 Folsom Dr Indianapolis Indiana Code: CRUST
  • Decatur Plastic Products, Inc Address: 3250 N State Highway 7 North Vernon Indiana Code: DECAT
  • Depco Address: 11827 Greenfield Avenue Noblesville Indiana Code: DEPCO
  • Derby Supply Chain Solutions Address: 4301 W 73 st Anderson Indiana Code: DERBY
  • Direct Shot Distributing, LLC. Address: 2001 Commerce Pkwy Franklin Indiana Code: DSD
  • Eagle Battery, LLC. Address: 3720 South Hoyt Ave. Muncie Indiana Code: EAGLE
  • EnterMarket / Accion Address: 7901 W 21st Street, Ste 1X Indianapolis Indiana Code: ENTER
  • Facade Tek Address: 5110 West 76th Street Indianapolis Indiana Code: FACADE
  • Facility Concepts, Inc. Address: 7676 Zionsville Rd. Indianapolis Indiana Code: FACCONC
  • Facility Concepts - Peru Address: 801 N Clay Street Peru Indiana Code: FACPERU
  • Facility Concepts - Whitestown Address: 4881 Perry Worth Rd Whitestown Indiana Code: FACWHITE
  • Finish Line Address: 3308 N. Mitthoeffer Indianapolis Indiana Code: FINLINE
  • Flambeau Products, Inc. Address: 4325 Middle Road Columbus Indiana Code: FLAMBPRO
  • Forest Products Supply CO. Address: 310 S. Kitley Ave. Indianapolis Indiana Code: FOREST
  • FullBeauty Brands Address: 2300 Southeastern Avenue Indianapolis Indiana Code: FULLBEAUTY
  • Garden Cuts Address: 4501 Massachusetts Ave Indianapolis Indiana Code: GARDEN
  • Gared Sports Address: 9200 E 146th St Ste A Noblesville Indiana Code: GARED
  • George Utz, Inc. Address: 14000 N 250 W Edinburgh Indiana Code: GEO UTZ
  • Glasrite Address: 6790 E 32nd St Indianapolis Indiana Code: GLAS
  • GNC Address: 4055 S 500 E Bldg 7A Whitestown Indiana Code: GNC
  • Goodyear Wholesale Address: 5850 S. Kopetsky Drive, Unit A Indianapolis Indiana Code: GOODYR
  • Great Dane Limited Partnership Address: 2664 E US Hwy 40 East Brazil Indiana Code: GRDANE
  • Harlan Bakeries / Avon Address: 7597 East US Highway36 Avon Indiana Code: HARAV
  • Harlan Bakeries / Gtwn North Address: 7575 Georgetown Road Indianapolis Indiana Code: HARGT
  • Henry Schein Address: 5315 West 74th Street, Suite 100 Indianapolis Indiana Code: HENSCH
  • Herff Jones Address: 4601 W 62nd Street Indianapolis Indiana Code: HERFF
  • Heartland Food Producers Address: 14300 Clay Terrace Blvd. Suite 249 Carmel Indiana Code: HFP
  • Hisada America Address: 1191 S Walnut St Edinburg Indiana Code: HISADA
  • Hittle Landscape, Inc. Address: 17778 Sun Park Drive Westfield Indiana Code: HITTLE
  • Pro Unlimited Address: 2700 N. Richardt Avenue Indianapolis Indiana Code: HOUGHTON
  • Harding Poorman Group Address: 4923 West 78th Street Indianapolis Indiana Code: HPG
  • IDS Address: 9431 All Points Parkway Plainfield Indiana Code: IDS
  • Ingram Micro Mobility Address: 501 Airtech Parkway Plainfield Indiana Code: IMMI
  • Ingram Micro Mobility - ITAD Address: 5345 Decatur Blvd, Suite A Indianapolis Indiana Code: IMMIITAD
  • BrightPoint Services, LLC. Address: 6001 Global Distribution Way Louisville Kentucky Code: IMMI-KY
  • Ingram Micro Mobility JDC Metro Address: 250 Hilton Lane Jeffersonville Indiana Code: IMMIJEFF
  • Indianapolis Fruit Company, Inc. Address: 4501 Massachusetts Ave. Indianapolis Indiana Code: INDFRUIT
  • Insultech Address: 5730 Dividend Rd Indianapolis Indiana Code: INSULTECH
  • International Packaging & Specialties Address: 1414 West St Indianapolis Indiana Code: INTERPNS
  • Irsay Estate Address: 1711 W. 116th Street Carmel Indiana Code: IRSEST
  • Kid Glove Service, LLC. Address: 2525 N. Shadeland Ave. Indianapolis Indiana Code: KID
  • King Systems Address: 15011 Herriman Blvd. Noblesville Indiana Code: KING
  • Langham Address: Indiana Code: LANG
  • Lids Address: 5304 W. 74th St. Indianapolis Indiana Code: LID
  • LSC Communications Address: 5550 W. 74th Street Indianapolis Indiana Code: LSC
  • Lysse Industries, LLC Address: 8460 Bearing Drive Indianapolis Indiana Code: LYSSE
  • Mansfield-King, LLC Address: 6501 Julian Ave Indianapolis Indiana Code: MANSF
  • Mariah Foods Address: 1333 Indiana Ave. Columbus Indiana Code: MARH
  • Max Katz Bag Co., Inc. Address: 235 South LaSalle Street Indianapolis Indiana Code: MAX
  • Merchandise Warehouse Co., Inc Address: 1414 S West Street Indianapolis Indiana Code: MERCH
  • Mervis Industries, Inc. Address: 6550 E. 30th St, Ste 151 Indianapolis Indiana Code: MERVIS
  • Meyer Plastics Address: 5167 East 65th Street Indianapolis Indiana Code: MEYER
  • Morales Group Inc Address: 5628 W 74th Street Indianapolis Indiana Code: MGI
  • Micrometl Corp Address: 3035 N Shadeland Ave Indianapolis Indiana Code: MICRO
  • Monarch Beverage Company Address: 9347 Pendleton Pike Indianapolis Indiana Code: MONARCH
  • Moriden America Address: 9760 Mayflower Park Dr, Ste 100 Carmel Indiana Code: MORIDEN
  • Multi Packaging Solutions / Accion Address: 2020 Production Dr Indianapolis Indiana Code: MPS
  • Neill-LaVielle Supply Address: 1711 S. Floyd St. Louisville Kentucky Code: NEILL
  • Newell Brands Address: 9999 East 121st St Fishers Indiana Code: NEWBRA
  • Network Global Logistics Address: 250 S Kitley Ave Indianapolis Indiana Code: NGL
  • NHK Seating of America, Inc Address: 2298 West State Road 28 Frankfort Indiana Code: NHK
  • Nikkei MC Aluminum Co Address: 6875 South Inwood Drive Columbus Indiana Code: NIKKEI
  • Nitto Denko Address: 8119 Zionsville Rd Indianapolis Indiana Code: NITDEN
  • Neovia Logistics / Accion Address: 5151 W 76th St Indianapolis Indiana Code: NLA
  • Neovia / Greenwood Address: 850 N Graham Rd Greenwood Indiana Code: NVG
  • Package Right LLC Address: 811 Development Dr. Tipton Indiana Code: PACKRIGHT
  • Patriot Porcelain Address: 2500 N. Union St. Kokomo Indiana Code: PATRIOT
  • Peer Foods, Inc Address: 1825 Stout Field Terrace Indianapolis Indiana Code: PEER
  • Ferr Foods Group, Inc Address: 1999 Indiana Ave Columbus Indiana Code: PEERC
  • Piazza Produce, Inc Address: 5941 W 82nd Street Indianapolis Indiana Code: PIAZZA
  • Plastic Recyling Inc Address: 2015 S Pennsylvania St Indianapolis Indiana Code: PLAREC
  • Precision Propeller Industries, Inc. Address: 2427 N. Ritter Ave Indianapolis Indiana Code: PPI
  • Practrical Property Group Address: 17925 Sun Park Drive Westfield Indiana Code: PRACTICAL
  • Pratt Corporation Address: 3035 N Shadelend Ave Indianapolis Indiana Code: PRAT
  • Prime Distribution Services, Inc. Address: 9955 AllPoints Pkwy. Plainfield Indiana Code: PRIME
  • Print Resources Address: 1500 E Riverside Dr Indianapolis Indiana Code: PRINT
  • Priority Press, Inc. Address: 4026 W. 10th St. Indianapolis Indiana Code: PRIORITY
  • Pro Unlimited Address: 2700 N. Richardt Avenue Indianapolis Indiana Code: PRO
  • Pitney Bowes Park 100 Address: 15011 Herriman Blvd Noblesville Indiana Code: PSI
  • Pitney Bowes Whitestown Address: 5940 Industrial Court Indianapolis Indiana Code: PSIWHT
  • Polymertech PTS / Accion Address: 7736 Zionsville Road Indianapolis Indiana Code: PTS
  • Pyramid Paper Products Address: 725 S Mapleton St Columbus Indiana Code: PYR
  • Red Gold Inc. Address: PO Box 83 Elwood Indiana Code: REDG
  • Reflex Allen Address: 2655 Fortune Cir W Ste A Indianapolis Indiana Code: REFLEX
  • Rivar's Inc. Address: 9900 Westpoint Drive, Suite 132 Indianapolis Indiana Code: RIVA
  • RMIS Location Address: Code: RMIS
  • RR Donnelley Address: 5550 W. 74th Street Indianapolis Indiana Code: RRDONN
  • Ryder Conagra Address: 640 S State Road 39 Lebanon Indiana Code: RYDCON
  • Ryder Logistics Address: 9101 Orly Road Indianapolis Indiana Code: RYDPEP
  • Ryder Pitney Bowes Address: 5490 Industrial Court, Ste 100 Whitestown Indiana Code: RYDPIT
  • Ryder Whirlpool P1 Address: 2801 Airwest Blvd. Plainfield Indiana Code: RYDWHI
  • Ryder Xerox Address: 760 Commerce Parkway Greenwood Indiana Code: RYDXER
  • Sacoma International, Inc. Address: 955 S. Walnut St. Edinburg Indiana Code: SAC
  • Salsbery Brothers Landscaping Address: 4317 E 146th Street Carmel Indiana Code: SALSBERY
  • Schenker, Inc. Address: 6555 E. 30th Street Indianapolis Indiana Code: SCHEN
  • SGI Address: 8350 Allison Ave Indianapolis Indiana Code: SGI
  • Shenandoah Growers Address: 4001 West Minnesota Street, Suite 200 Indianapolis Indiana Code: SHEN
  • Shenandoah Special Projects Address: 4001 W Minnesota Street Indianapolis Indiana Code: SHENANDOAH
  • Spartan Warehouse & Distribution Company Address: 3333 Mesilla Ct. Indianapolis Indiana Code: SPART
  • S & S Steel Address: 444 East 29th Street Anderson Indiana Code: SSSTE
  • Staffmark / Home Depot Address: 1390 S. Perry Road Plainfield Indiana Code: STAFF-HD
  • OHL Contract Logistics / Accion Address: 1100 Whitaker Rd. Plainfield Indiana Code: STAFF-OHL
  • Stanly Black and Decker Address: 501 W New Road Greenfield Indiana Code: STANLEYB
  • Stratosphere Quality, LLC Address: 12024 Exit 5 Parkway Fishers Indiana Code: STRATOS
  • Sunright America, Inc. Address: 6205 South International Drive Columbus Indiana Code: SUNRIGHT
  • Superior Metal Technologies LLC Address: 9850 E. 30th St. Indianapolis Indiana Code: SUPMETAL
  • Sur La Table Address: 901 E Northfield Drive Brownsburg Indiana Code: SURLA
  • Telamon Corp Address: 1000 E 116th St Carmel Indiana Code: TELAMON
  • Tempur Sealy International, Inc Address: 1000 Tempur Way Lexington Kentucky Code: TEMPUR
  • Enbi Indiana, Inc. Address: 1703 McCall Drive Shelbyville Indiana Code: TENCATE
  • Thermal Structures, Inc. Address: 2800 Airwest Blvd Plainfield Indiana Code: THER
  • Tridien Medical Address: 9901 Kincaid Drive, Suite 200 Fishers Indiana Code: TRIDIEN
  • Trinity Metals LLC Address: 6400 English Avenue Indianapolis Indiana Code: TRINITY
  • United Hospital Services, LLC. Address: 9948 Park Davis Dr. Indianapolis Indiana Code: UNIHOSP
  • Venture Logistics Address: 7901 W. 21st St. Indianapolis Indiana Code: VENTURE
  • Volt/Stericycle Address: 6026 Lakeside Blvd Indianapolis Indiana Code: VOLSTE
  • Westcon Group, Inc Address: 595 Perry Road Plainfield Indiana Code: WESTCON

• New Client:

ASSOCIATE INFORMATION

• Associate Name:

• SSN:

• Sex:

  Female

  Male

  Transgender

• Address (Street, City, State and Zip)

• Date of Birth: (MM/DD/YYYY)

• Date of Hire: (MM/DD/YYYY)

• Phone:

INFORMATION ABOUT THE CASE

• Associate Job Title:

  Select General Labor Forklift drivers Warehouse Associate Warehouse pick/pack Picker Packer Manufacturing Other

  • General Labor
  • Forklift drivers
  • Warehouse Associate
  • Warehouse pick/pack
  • Picker
  • Packer
  • Manufacturing
  • Other

• Shift:

  First (Morning)

  Second (Evening)

  Third (Mixed)

• Time employee began work:

  Date

• Date and Time of Injury or Illness :

  Date

• Add drawing

  Drawing

• Part of Body Affected

  Select Head Eye / L Eye / R Shoulder / L Shoulder / R Arm / L Arm / R Elbow / L Elbow / R Wrist / L Wrist / R Hand / L Hand / R Finger (Specify) Back (Upper Back) Back (Lower Back) Chest Abdomen Pelvis Hip / L Hip / R Leg / L Leg / R Knee / L Knee / R Ankle / L Ankle / R Foot / L Foot / R Toe (Specify) Other

  • Head
  • Eye / L
  • Eye / R
  • Shoulder / L
  • Shoulder / R
  • Arm / L
  • Arm / R
  • Elbow / L
  • Elbow / R
  • Wrist / L
  • Wrist / R
  • Hand / L
  • Hand / R
  • Finger (Specify)
  • Back (Upper Back)
  • Back (Lower Back)
  • Chest
  • Abdomen
  • Pelvis
  • Hip / L
  • Hip / R
  • Leg / L
  • Leg / R
  • Knee / L
  • Knee / R
  • Ankle / L
  • Ankle / R
  • Foot / L
  • Foot / R
  • Toe (Specify)
  • Other

• Other parts of the body affected? (Specify)

• Type of Injury

  Select Abrasion (Chemical burns) Scrape Amputation Bite Bruise Burn Concussion Cut / Laceration Foreign Body Fracture Hearing Impaired Infection Pain Puncture Rash / Dermatitis Respiratory Strain / Sprain Illness Other

  • Abrasion (Chemical burns)
  • Scrape
  • Amputation
  • Bite
  • Bruise
  • Burn
  • Concussion
  • Cut / Laceration
  • Foreign Body
  • Fracture
  • Hearing Impaired
  • Infection
  • Pain
  • Puncture
  • Rash / Dermatitis
  • Respiratory
  • Strain / Sprain
  • Illness
  • Other

• Was it Fatal?

  Yes

  No

  N/A

• If the employee died, when did death occur? (Date of death)….. Safety must be reported to OSHA within 8 hours.

• WHERE...?

• WHERE, exactly did the accident occurred?

• WHAT...??

• WHAT was the employee doing just before the accident occurred?

• HOW...???
  Please describe, step-by-step, the events that led to the injury. Include names of machinery, parts, objects, tools, materials, and other important details:

• HOW did the injury occurred? *Note: Be as descriptive as possible *

• Was PPE (Personal Protective Equipment) used?

  Yes

  No

  N/A

• What type:

• Did injured employee miss work?

  Yes

  No

  N/A

• Were there any witnesses to the accident?

• Witness Name:

• Phone:

• Other:

  Yes

  No

  N/A

Completed by:

• Supervisor’s Name:

• Supervisor’s Phone:

• Supervisor’s Signature:

  Sign

• Additional follow up needed?

  Yes

  No

  N/A

• If Yes, please explain:

  Yes

  No

  N/A

• **THIS FORM MUST BE SUBMITTED TO MORALES GROUP – WITHIN 24 HOURS OF INCIDENT**
  
  Injuryreports@moralesgroup.net
  
  claimsexpress@unitedheartland.com
  0000000 0000 000