Title Page
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Conducted on
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Prepared by
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Location
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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.
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**IMPORTANT** PLEASE SUBMIT THIS FORM WITHIN 24 HOURS OF INJURY.
mail: Injuryreports@moralesgroup.net
mail: claimsexpress@unitedheartland.com
Phone : 0000 000 000
CLIENT INFORMATION
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Client:
- 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
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New Client:
ASSOCIATE INFORMATION
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Associate Name:
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SSN:
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Sex:
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Address (Street, City, State and Zip)
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Date of Birth: (MM/DD/YYYY)
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Date of Hire: (MM/DD/YYYY)
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Phone:
INFORMATION ABOUT THE CASE
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Associate Job Title:
- General Labor
- Forklift drivers
- Warehouse Associate
- Warehouse pick/pack
- Picker
- Packer
- Manufacturing
- Other
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Shift:
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Time employee began work:
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Date and Time of Injury or Illness :
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Add drawing
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Part of Body Affected
- 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
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Other parts of the body affected? (Specify)
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Type of Injury
- 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
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Was it Fatal?
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If the employee died, when did death occur? (Date of death)….. Safety must be reported to OSHA within 8 hours.
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WHERE...?
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WHERE, exactly did the accident occurred?
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WHAT...??
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WHAT was the employee doing just before the accident occurred?
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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 *
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Was PPE (Personal Protective Equipment) used?
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What type:
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Did injured employee miss work?
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Were there any witnesses to the accident?
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Witness Name:
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Phone:
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Other:
Completed by:
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Supervisor’s Name:
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Supervisor’s Phone:
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Supervisor’s Signature:
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Additional follow up needed?
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If Yes, please explain:
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**THIS FORM MUST BE SUBMITTED TO MORALES GROUP – WITHIN 24 HOURS OF INCIDENT**
Injuryreports@moralesgroup.net
claimsexpress@unitedheartland.com
0000000 0000 000
