MGI-INJURY AND ILLNESS REPORT

• Conducted on

  Date

• Prepared by

• Location
  Address

• INSTRUCTIONS:
  
  1. Please complete the Report of Injury in its entirety.
  a. To be completed by the Employer. (e. g. AM, OM, BL, PM, or Direct Supervisor)
  b. Marked in red is mandatory
  c. Please complete within 24 hours of employer's knowledge.
  
  2. Send Injury and Illness Report to: Injuryreports@moralesgroup.net
  a. Do not wait for medical bills or hold them before filing an Injury Report.
  b. Send medical bills or supporting documents on previously submitted Injury Report.
  
  3. Any questions about completing this form, please check with your direct supervisor.
  
  *** SSN is for internal use and to report a work injury or illness only.
  
  
  

YOUR INSURANCE CARRIER IS: (MGI)

• MGI: United Heartland Your policy number is: 0400163126 Effective Dates: 12/2/2018 – 12/2/2019 Their telephone number is: 800-258-2667 Their email address is: UHadminSVC@unitedheartland.biz

  CALIDAD: Liberty Mutual Insurance Your policy number is: WC539S363510 Effective dates: 3/25/2018 – 3/25/2019 Their telephone number is: 800-653-7893 Their email address is: imf@libertymutual.com

CLIENT-COMPANY INFORMATION: (This is where the accident Happened.)

• Client-Company Name:

  Select Accion Performance Code: ACCION Adress: 8161 Zionsville Rd. Indianapolis IN Accurate Manufacturing Code: ACCURATE Adress: 8090 Woodland Drive Indianapolis IN Advanced Distribution Code: ADVDISTR Adress: 8019 Allison Avenue Indianapolis IN AEF Construction, LLC. Code: AETNA Adress: 14032 Britton Park Rd. Fishers IN Alom Technologies Code: ALOM Adress: 2670 Executive Dr. Indianapolis IN Alsco Code: ALSCO Adress: 711 E. Vermont Street Indianapolis IN Arrow Container Code: ARROW Adress: 2900 Shadeland Ave Indianapolis IN Arvco Container Corp. Code: ARVCO Adress: 8219 Northwest Blvd, Ste 150 Indianapolis IN Automatic Distributors Code: AUTDIS Adress: 5111 W. 76th St. Indianapolis IN Automatic Pool Covers Code: AUTPOO Adress: 17397 Oak Ridge Road Westfield IN Beacon Industries Code: BEACON Adress: 912 S Walnut St Edinburgh IN Belkin/Accion Code: BELKIN Adress: 558 Airtech Parkway Plainfield IN Biometrics ATL Code: BIO Adress: 6102 Victory Way Indianapolis IN Blue Marble Cocktails Code: BLUE Adress: 60080 Corporate Way Indianapolis IN BRIGHTVIEW Code: BVL Adress: 5635 Progress St Indianapolis IN BSN Sport, Inc Code: BSN Adress: 5345 W. 76th Indianapolis IN Caito Food Service Inc. Code: CAIT Adress: 3120 North Post Road Indianapolis IN Caltherm, Inc. Code: CALTH Adress: 910 S. Gladstone Ave. Columbus IN Carter Lumber Company Code: CARTER Adress: 2901 N Morton Street Franklin IN Catheter Research, Inc Code: CATH Adress: 6102 Victory Way Indianapolis IN Ceva Logistics Park 100 Code: CEVA Adress: 7365 Winton Drive Indianapolis IN Cintas Uniform Services Code: CINTAS Adress: 7258 Georgetown Road Indianapolis IN CloudBlue Technologies, Inc. Code: CLOUDBLUE Adress: 5345 Decatur Blvd, Suite A Indianapolis IN Columbus Container, Inc. Code: COLCONT Adress: 3460 Commerce Dr. Columbus IN CPS, Inc Code: CPS Adress: 5648 West 82nd St Indianapolis IN Cross Road Centers / Accion Code: CRC Adress: 8192 Allison Ave Indianapolis IN Crust N More Inc Code: CRUST Adress: 10516 Folsom Dr Indianapolis IN Decatur Plastic Products, Inc Code: DECAT Adress: 3250 N State Highway 7 North Vernon IN Depco Code: DEPCO Adress: 11827 Greenfield Avenue Noblesville IN Derby Supply Chain Solutions Code: DERBY Adress: 4301 W 73rd Street Anderson IN Enbi Indiana, Inc. Code: TENCATE Adress: 1703 McCall Drive Shelbyville IN EnterMarket / Accion Code: ENTER Adress: 7901 W 21st Street, Ste 1X Indianapolis IN Facade Tek Code: FACADE Adress: 5110 West 76th Street Indianapolis IN Facility Concepts - Peru Code: FACPERU Adress: 801 N Clay Street Peru IN Facility Concepts - Whitestown Code: FACWHITE Adress: 4881 Perry Worth Rd Whitestown IN Facility Concepts, Inc. Code: FACCONC Adress: 7676 Zionsville Rd. Indianapolis IN Ferr Foods Group, Inc Code: PEERC Adress: 1999 Indiana Ave. Columbus IN Finish Line Code: FINLINE Adress: 3308 N. Mitthoeffer Indianapolis IN Flambeau Products Inc Code: FLAMBPRO Adress: 4325 Middle Road Columbus IN Forest Products Supply CO. Code: FOREST Adress: 310 S. Kitley Ave. Indianapolis IN FullBeauty Brands Code: FULLBEAUTY Adress: 7676 Zionsville Rd Indianapolis IN Garden Cuts Code: GARDEN Adress: 4501 Massachusetts Ave Indianapolis IN Gared Sports Code: GARED Adress: 9200 E 146th St Ste A Noblesville IN George Utz, Inc. Code: GEO UTZ Adress: 14000 N 250 W Edinburgh IN GLASRITE Code: GLAS Adress: 6790 E 32nd St Indianapolis IN GNC Code: GNC Adress: 4055 S 500 E Bldg 7A Whitestown IN Great Dane Limited Partnership Code: GRDANE Adress: 2664 E US Hwy 40 East Brazil IN Harding Poorman Group Code: HPG Adress: 4923 West 78th Street Indianapolis IN Heartland FPG Code: HFPG Adress: 4635 W. 84th Street Indianapolis IN Henry Schein Code: HENSCH Adress: 5315 West 74th Street, Suite 100 Indianapolis IN Herff Jones Code: HERFF Adress: 4601 W 62nd Street Indianapolis IN Hisada America Code: HISADA Adress: 1191 S Walnut St Edinburg IN Hittle Landscape, Inc. Code: HITTLE Adress: 17778 Sun Park Drive Westfield IN Home Design Products Code: HDP Adress: 6435 S. Scatterfield Rd. Anderson IN IDS Code: IDS Adress: 9431 All Points Parkway Plainfield IN Indiana Automotive Fasteners Inc. Code: IAF Adress: 1300 W Anderson Blvd Greenfield IN Indianapolis Fruit Company, Inc. Code: INDFRUIT Adress: 4501 Massachusetts Ave. Indianapolis IN Ingram Micro Mobility Code: IMMI Adress: 501 Airtech Parkway Plainfield IN Ingram Micro Mobility - ITAD Code: IMMIITAD Adress: 5345 Decatur Blvd Indianapolis IN Ingram Micro Mobility JDC Metro Code: IMMIJEFF Adress: 250 Hilton Lane Jeffersonville IN Ingram Micro/DC Code: IMMIPDC Adress: 1451 Allpoints Ct. Plainfield IL Insultech Code: INSULTECH Adress: 5730 Dividend Rd Indianapolis IN International Packaging & Specialties Code: INTERPNS Adress: 1414 West St Indianapolis IN Irsay Estate Code: IRSEST Adress: 1711 W. 116th Street Carmel IN Kelly Services Code: BECKCOULT Adress: 5355 W. 76th St. Indianapolis IN Kid Glove Service, LLC. Code: KID Adress: 2525 N. Shadeland Ave. Indianapolis IN King Systems Code: KING Adress: 15011 Herriman Blvd. Noblesville IN King Systems Code: AMBU Adress: 15011 Herriman Blvd. Noblesville IN LaCrosse Footwear Code: LAX Adress: 5352 Performance Way Whitestown IN Langham Code: LANG Adress: Park 100 5335 W. 74th St Indianapolis IN Lids Code: LID Adress: 5304 W. 74th St. Indianapolis IN Lift a Loft Corp Code: LIFT Adress: 9501 S. Center Rd. Muncie IN LSC Communications Code: LSC Adress: 5550 W. 74th Street Indianapolis IN Lysse Industries, LLC Code: LYSSE Adress: 8460 Bearing Drive Indianapolis IN Mansfield-King, LLC Code: MANSF Adress: 6501 Julian Ave Indianapolis IN Mariah Foods Code: MARH Adress: 1333 Indiana Ave. Columbus IN Masolite Code: MASO Adress: 2415 Alexandria Pike Anderson IN Max Katz Bag Co., Inc. Code: MAX Adress: 235 South LaSalle Street Indianapolis IN Merchandise Warehouse Co., Inc Code: MERCH Adress: 1414 S West Street Indianapolis IN Mervis Industries, Inc. Code: MERVIS Adress: 6550 E. 30th St, Ste 151 Indianapolis IN Meyer Plastics Code: MEYER Adress: 5167 East 65th Street Indianapolis IN Micrometl Corp Code: MICRO Adress: 3035 N Shadeland Ave Indianapolis IN Monarch Beverage Company Code: MONARCH Adress: 9347 Pendleton Pike Indianapolis IN Morales Group Inc Code: MGI Adress: 5628 W 74th Street Indianapolis IN Moriden America Code: MORIDEN Adress: 9760 Mayflower Park Dr, Ste 100 Carmel IN Multi Packaging Solutions / Accion Code: MPS Adress: 2020 Production Dr Indianapolis IN NEOVIA Logistics/Accion Code: NLA Adress: 5151 W 76th St Indianapolis IN NEOVIA/Greenwood Code: NVG Adress: 850 N Graham Rd Greenwood IN Network Global Logistics Code: NGL Adress: 250 S Kitley Ave Indianapolis IN Newell Brands Code: NEWBRA Adress: 9999 East 121st Street Fishers IN NHK Seating of America, Inc Code: NHK Adress: 2298 West State Road 28 Frankfort IN Nikkei MC Aluminum Co Code: NIKKEI Adress: 6875 South Inwood Drive Columbus IN Nitto Denko Code: NITDEN Adress: 8119 Zionsville Rd. Indianapolis IN Package Right LLC Code: PACKRIGHT Adress: 811 Development Dr. Tipton IN Packaging Corporation of America Code: PACCOROFA Adress: 3460 Commerce Dr. Columbus IN Peer Foods, Inc Code: PEER Adress: 1825 Stout Field Terrace Indianapolis IN Perry Foam Products, Inc. Code: PERRY Adress: 2335 S. 30th Street Lafayette IN Pet Supplies Plus Code: PETSUP Adress: 1510 East 4th Street Seymour IN Piazza Produce, Inc Code: PIAZZA Adress: 5941 W 82nd Street Indianapolis IN Pitney Bowes Park 100 Code: PSI Adress: 15011 Herriman Blvd Noblesville IN Pitney Bowes Presort Services Code: PSIPS Adress: 7236 Winton Dr Indianapolis IN Pitney Bowes Whitestown Code: PSIWHT Adress: 5940 Industrial Court Indianapolis IN Plastic Recycling Inc Code: PLAREC Adress: 2015 S. Pennsylvania Street Indianapolis IN Plastic Recycling Inc Code: PLASTIC Adress: 2015 S Pennsylvania St Indianapolis IN Polymertech PTS / Accion Code: PTS Adress: 7736 Zionsville Road Indianapolis IN Porter Engineered Systems Code: PORT Adress: 2000 E. 196th Street Westfield IN Practical Property Group Code: PRACTICAL Adress: 17925 Sun Park Drive Westfield IN Pratt Corporation Code: PRAT Adress: 3035 N Shadelend Ave Indianapolis IN Precision Propeller Industries, Inc. Code: PPI Adress: 2427 N. Ritter Ave Indianapolis IN Prime Distribution Services, Inc. Code: PRIME Adress: 9955 AllPoints Pkwy. Plainfield IN Print Resources Code: PRINT Adress: 1500 E. Riverside Dr. Indianapolis IN Priority Press, Inc. Code: PRIORITY Adress: 4026 W. 10th St. Indianapolis IN Pro Unlimited Code: PRO Adress: 2700 N. Richardt Avenue Indianapolis IN Pro Unlimited Code: HOUGHTON Adress: 2700 N. Richardt Avenue Indianapolis IN Red Gold Inc. Code: REDG Adress: PO Box 83 Elwood IN Reflex Allen Code: REFLEX Adress: 2655 Fortune Cir W Ste A Indianapolis IN Rightway Fasteners Code: RIGFAS Adress: 7945 S. International Dr. Columbus IN RR Donnelley Code: RRDONN Adress: 5550 W. 74th Street Indianapolis IN Ryder Conagra Code: RYDCON Adress: 3500 w Co Rd O Ns Frankfort IN 46041 Ryder Logistics Code: RYDPEP Adress: 9101 Orly Road Indianapolis IN Ryder Pitney Bowes Code: RYDPIT Adress: 5490 Industrial Court, Ste 100 Whitestown IN Ryder Xerox Code: RYDXER Adress: 760 Commerce Way Greenwood IN Ryder/Amazon PIN1 Code: RYDERAMZ Adress: 6161 Decatur Blvd. Suite B Indianapolis IN Salsbery Brothers Landscaping Code: SALSBERY Adress: 4317 E 146th Street Carmel IN Schenker, Inc. Code: SCHEN Adress: 6555 E. 30th Street Indianapolis IN Schuetz Container Sy Code: SCHUETZ Adress: 2375 Reeves Dr. Plainfield IN SGI Code: SGI Adress: 8350 Allison Ave Indianapolis IN Shenandoah Growers Code: SHEN Adress: 4001 West Minnesota Street, Suite 200 Indianapolis IN Spartan Warehouse & Distribution Company Code: SPART Adress: 3333 Mesilla Ct. Indianapolis IN Stanley Black and Decker Code: STANLEYB Adress: 501 W. New Road Greenfield IN Stratosphere Quality, LLC Code: STRATOS Adress: 12024 Exit 5 Parkway Fishers IN Sunright America, Inc. Code: SUNRIGHT Adress: 6205 South International Drive Columbus IN Superior Metal Technologies LLC Code: SUPMETAL Adress: 9850 E. 30th St. Indianapolis IN Sur La Table Code: SURLA Adress: 901 E Northfield Drive Brownsburg IN Telamon Corp Code: TELAMON Adress: 1000 E 116th St Carmel IN Thermal Structures, Inc. Code: THER Adress: 2800 Airwest Blvd Plainfield IN Tridien Medical Code: TRIDIEN Adress: 9901 Kincaid Drive, Suite 200 Fishers IN Trinity Metals LLC Code: TRINITY Adress: 6400 English Avenue Indianapolis IN United Hospital Services, LLC. Code: UNIHOSP Adress: 9948 Park Davis Dr. Indianapolis IN Venture Logistics Code: VENTURE Adress: 7901 W. 21st St. Indianapolis IN Westcon Group, Inc Code: WESTCON Adress: 595 Perry Road Plainfield IN AEL SPAN Code: AELS Adress: 6712 Grade Lane #509 Louisville KY Bloemer Food Sales Code: BLOEMER Adress: 925 S 7th Street Louisville KY BrightPoint Services, LLC. Code: IMMI-KY Adress: 6001 Global Distribution Way Louisville KY CloudBlue Tech., Inc. Code: CLOUDBLUE-KY Adress: 1135 Aviation Rd. Hebron KY Ingram Micro/Levi Code: IMMIL Adress: 6001 Global Distribution Way Louisville KY Neill-LaVielle Supply Code: NEILL Adress: 1711 S. Floyd St. Louisville KY Solutions 2 Go/Accion Code: SOLU2G Adress: 5000 Commerce Crossings Louisville KY Tempur Sealy International, Inc Code: TEMPUR Adress: 1000 Tempur Way Lexington KY

  • Accion Performance Code: ACCION Adress: 8161 Zionsville Rd. Indianapolis IN
  • Accurate Manufacturing Code: ACCURATE Adress: 8090 Woodland Drive Indianapolis IN
  • Advanced Distribution Code: ADVDISTR Adress: 8019 Allison Avenue Indianapolis IN
  • AEF Construction, LLC. Code: AETNA Adress: 14032 Britton Park Rd. Fishers IN
  • Alom Technologies Code: ALOM Adress: 2670 Executive Dr. Indianapolis IN
  • Alsco Code: ALSCO Adress: 711 E. Vermont Street Indianapolis IN
  • Arrow Container Code: ARROW Adress: 2900 Shadeland Ave Indianapolis IN
  • Arvco Container Corp. Code: ARVCO Adress: 8219 Northwest Blvd, Ste 150 Indianapolis IN
  • Automatic Distributors Code: AUTDIS Adress: 5111 W. 76th St. Indianapolis IN
  • Automatic Pool Covers Code: AUTPOO Adress: 17397 Oak Ridge Road Westfield IN
  • Beacon Industries Code: BEACON Adress: 912 S Walnut St Edinburgh IN
  • Belkin/Accion Code: BELKIN Adress: 558 Airtech Parkway Plainfield IN
  • Biometrics ATL Code: BIO Adress: 6102 Victory Way Indianapolis IN
  • Blue Marble Cocktails Code: BLUE Adress: 60080 Corporate Way Indianapolis IN
  • BRIGHTVIEW Code: BVL Adress: 5635 Progress St Indianapolis IN
  • BSN Sport, Inc Code: BSN Adress: 5345 W. 76th Indianapolis IN
  • Caito Food Service Inc. Code: CAIT Adress: 3120 North Post Road Indianapolis IN
  • Caltherm, Inc. Code: CALTH Adress: 910 S. Gladstone Ave. Columbus IN
  • Carter Lumber Company Code: CARTER Adress: 2901 N Morton Street Franklin IN
  • Catheter Research, Inc Code: CATH Adress: 6102 Victory Way Indianapolis IN
  • Ceva Logistics Park 100 Code: CEVA Adress: 7365 Winton Drive Indianapolis IN
  • Cintas Uniform Services Code: CINTAS Adress: 7258 Georgetown Road Indianapolis IN
  • CloudBlue Technologies, Inc. Code: CLOUDBLUE Adress: 5345 Decatur Blvd, Suite A Indianapolis IN
  • Columbus Container, Inc. Code: COLCONT Adress: 3460 Commerce Dr. Columbus IN
  • CPS, Inc Code: CPS Adress: 5648 West 82nd St Indianapolis IN
  • Cross Road Centers / Accion Code: CRC Adress: 8192 Allison Ave Indianapolis IN
  • Crust N More Inc Code: CRUST Adress: 10516 Folsom Dr Indianapolis IN
  • Decatur Plastic Products, Inc Code: DECAT Adress: 3250 N State Highway 7 North Vernon IN
  • Depco Code: DEPCO Adress: 11827 Greenfield Avenue Noblesville IN
  • Derby Supply Chain Solutions Code: DERBY Adress: 4301 W 73rd Street Anderson IN
  • Enbi Indiana, Inc. Code: TENCATE Adress: 1703 McCall Drive Shelbyville IN
  • EnterMarket / Accion Code: ENTER Adress: 7901 W 21st Street, Ste 1X Indianapolis IN
  • Facade Tek Code: FACADE Adress: 5110 West 76th Street Indianapolis IN
  • Facility Concepts - Peru Code: FACPERU Adress: 801 N Clay Street Peru IN
  • Facility Concepts - Whitestown Code: FACWHITE Adress: 4881 Perry Worth Rd Whitestown IN
  • Facility Concepts, Inc. Code: FACCONC Adress: 7676 Zionsville Rd. Indianapolis IN
  • Ferr Foods Group, Inc Code: PEERC Adress: 1999 Indiana Ave. Columbus IN
  • Finish Line Code: FINLINE Adress: 3308 N. Mitthoeffer Indianapolis IN
  • Flambeau Products Inc Code: FLAMBPRO Adress: 4325 Middle Road Columbus IN
  • Forest Products Supply CO. Code: FOREST Adress: 310 S. Kitley Ave. Indianapolis IN
  • FullBeauty Brands Code: FULLBEAUTY Adress: 7676 Zionsville Rd Indianapolis IN
  • Garden Cuts Code: GARDEN Adress: 4501 Massachusetts Ave Indianapolis IN
  • Gared Sports Code: GARED Adress: 9200 E 146th St Ste A Noblesville IN
  • George Utz, Inc. Code: GEO UTZ Adress: 14000 N 250 W Edinburgh IN
  • GLASRITE Code: GLAS Adress: 6790 E 32nd St Indianapolis IN
  • GNC Code: GNC Adress: 4055 S 500 E Bldg 7A Whitestown IN
  • Great Dane Limited Partnership Code: GRDANE Adress: 2664 E US Hwy 40 East Brazil IN
  • Harding Poorman Group Code: HPG Adress: 4923 West 78th Street Indianapolis IN
  • Heartland FPG Code: HFPG Adress: 4635 W. 84th Street Indianapolis IN
  • Henry Schein Code: HENSCH Adress: 5315 West 74th Street, Suite 100 Indianapolis IN
  • Herff Jones Code: HERFF Adress: 4601 W 62nd Street Indianapolis IN
  • Hisada America Code: HISADA Adress: 1191 S Walnut St Edinburg IN
  • Hittle Landscape, Inc. Code: HITTLE Adress: 17778 Sun Park Drive Westfield IN
  • Home Design Products Code: HDP Adress: 6435 S. Scatterfield Rd. Anderson IN
  • IDS Code: IDS Adress: 9431 All Points Parkway Plainfield IN
  • Indiana Automotive Fasteners Inc. Code: IAF Adress: 1300 W Anderson Blvd Greenfield IN
  • Indianapolis Fruit Company, Inc. Code: INDFRUIT Adress: 4501 Massachusetts Ave. Indianapolis IN
  • Ingram Micro Mobility Code: IMMI Adress: 501 Airtech Parkway Plainfield IN
  • Ingram Micro Mobility - ITAD Code: IMMIITAD Adress: 5345 Decatur Blvd Indianapolis IN
  • Ingram Micro Mobility JDC Metro Code: IMMIJEFF Adress: 250 Hilton Lane Jeffersonville IN
  • Ingram Micro/DC Code: IMMIPDC Adress: 1451 Allpoints Ct. Plainfield IL
  • Insultech Code: INSULTECH Adress: 5730 Dividend Rd Indianapolis IN
  • International Packaging & Specialties Code: INTERPNS Adress: 1414 West St Indianapolis IN
  • Irsay Estate Code: IRSEST Adress: 1711 W. 116th Street Carmel IN
  • Kelly Services Code: BECKCOULT Adress: 5355 W. 76th St. Indianapolis IN
  • Kid Glove Service, LLC. Code: KID Adress: 2525 N. Shadeland Ave. Indianapolis IN
  • King Systems Code: KING Adress: 15011 Herriman Blvd. Noblesville IN
  • King Systems Code: AMBU Adress: 15011 Herriman Blvd. Noblesville IN
  • LaCrosse Footwear Code: LAX Adress: 5352 Performance Way Whitestown IN
  • Langham Code: LANG Adress: Park 100 5335 W. 74th St Indianapolis IN
  • Lids Code: LID Adress: 5304 W. 74th St. Indianapolis IN
  • Lift a Loft Corp Code: LIFT Adress: 9501 S. Center Rd. Muncie IN
  • LSC Communications Code: LSC Adress: 5550 W. 74th Street Indianapolis IN
  • Lysse Industries, LLC Code: LYSSE Adress: 8460 Bearing Drive Indianapolis IN
  • Mansfield-King, LLC Code: MANSF Adress: 6501 Julian Ave Indianapolis IN
  • Mariah Foods Code: MARH Adress: 1333 Indiana Ave. Columbus IN
  • Masolite Code: MASO Adress: 2415 Alexandria Pike Anderson IN
  • Max Katz Bag Co., Inc. Code: MAX Adress: 235 South LaSalle Street Indianapolis IN
  • Merchandise Warehouse Co., Inc Code: MERCH Adress: 1414 S West Street Indianapolis IN
  • Mervis Industries, Inc. Code: MERVIS Adress: 6550 E. 30th St, Ste 151 Indianapolis IN
  • Meyer Plastics Code: MEYER Adress: 5167 East 65th Street Indianapolis IN
  • Micrometl Corp Code: MICRO Adress: 3035 N Shadeland Ave Indianapolis IN
  • Monarch Beverage Company Code: MONARCH Adress: 9347 Pendleton Pike Indianapolis IN
  • Morales Group Inc Code: MGI Adress: 5628 W 74th Street Indianapolis IN
  • Moriden America Code: MORIDEN Adress: 9760 Mayflower Park Dr, Ste 100 Carmel IN
  • Multi Packaging Solutions / Accion Code: MPS Adress: 2020 Production Dr Indianapolis IN
  • NEOVIA Logistics/Accion Code: NLA Adress: 5151 W 76th St Indianapolis IN
  • NEOVIA/Greenwood Code: NVG Adress: 850 N Graham Rd Greenwood IN
  • Network Global Logistics Code: NGL Adress: 250 S Kitley Ave Indianapolis IN
  • Newell Brands Code: NEWBRA Adress: 9999 East 121st Street Fishers IN
  • NHK Seating of America, Inc Code: NHK Adress: 2298 West State Road 28 Frankfort IN
  • Nikkei MC Aluminum Co Code: NIKKEI Adress: 6875 South Inwood Drive Columbus IN
  • Nitto Denko Code: NITDEN Adress: 8119 Zionsville Rd. Indianapolis IN
  • Package Right LLC Code: PACKRIGHT Adress: 811 Development Dr. Tipton IN
  • Packaging Corporation of America Code: PACCOROFA Adress: 3460 Commerce Dr. Columbus IN
  • Peer Foods, Inc Code: PEER Adress: 1825 Stout Field Terrace Indianapolis IN
  • Perry Foam Products, Inc. Code: PERRY Adress: 2335 S. 30th Street Lafayette IN
  • Pet Supplies Plus Code: PETSUP Adress: 1510 East 4th Street Seymour IN
  • Piazza Produce, Inc Code: PIAZZA Adress: 5941 W 82nd Street Indianapolis IN
  • Pitney Bowes Park 100 Code: PSI Adress: 15011 Herriman Blvd Noblesville IN
  • Pitney Bowes Presort Services Code: PSIPS Adress: 7236 Winton Dr Indianapolis IN
  • Pitney Bowes Whitestown Code: PSIWHT Adress: 5940 Industrial Court Indianapolis IN
  • Plastic Recycling Inc Code: PLAREC Adress: 2015 S. Pennsylvania Street Indianapolis IN
  • Plastic Recycling Inc Code: PLASTIC Adress: 2015 S Pennsylvania St Indianapolis IN
  • Polymertech PTS / Accion Code: PTS Adress: 7736 Zionsville Road Indianapolis IN
  • Porter Engineered Systems Code: PORT Adress: 2000 E. 196th Street Westfield IN
  • Practical Property Group Code: PRACTICAL Adress: 17925 Sun Park Drive Westfield IN
  • Pratt Corporation Code: PRAT Adress: 3035 N Shadelend Ave Indianapolis IN
  • Precision Propeller Industries, Inc. Code: PPI Adress: 2427 N. Ritter Ave Indianapolis IN
  • Prime Distribution Services, Inc. Code: PRIME Adress: 9955 AllPoints Pkwy. Plainfield IN
  • Print Resources Code: PRINT Adress: 1500 E. Riverside Dr. Indianapolis IN
  • Priority Press, Inc. Code: PRIORITY Adress: 4026 W. 10th St. Indianapolis IN
  • Pro Unlimited Code: PRO Adress: 2700 N. Richardt Avenue Indianapolis IN
  • Pro Unlimited Code: HOUGHTON Adress: 2700 N. Richardt Avenue Indianapolis IN
  • Red Gold Inc. Code: REDG Adress: PO Box 83 Elwood IN
  • Reflex Allen Code: REFLEX Adress: 2655 Fortune Cir W Ste A Indianapolis IN
  • Rightway Fasteners Code: RIGFAS Adress: 7945 S. International Dr. Columbus IN
  • RR Donnelley Code: RRDONN Adress: 5550 W. 74th Street Indianapolis IN
  • Ryder Conagra Code: RYDCON Adress: 3500 w Co Rd O Ns Frankfort IN 46041
  • Ryder Logistics Code: RYDPEP Adress: 9101 Orly Road Indianapolis IN
  • Ryder Pitney Bowes Code: RYDPIT Adress: 5490 Industrial Court, Ste 100 Whitestown IN
  • Ryder Xerox Code: RYDXER Adress: 760 Commerce Way Greenwood IN
  • Ryder/Amazon PIN1 Code: RYDERAMZ Adress: 6161 Decatur Blvd. Suite B Indianapolis IN
  • Salsbery Brothers Landscaping Code: SALSBERY Adress: 4317 E 146th Street Carmel IN
  • Schenker, Inc. Code: SCHEN Adress: 6555 E. 30th Street Indianapolis IN
  • Schuetz Container Sy Code: SCHUETZ Adress: 2375 Reeves Dr. Plainfield IN
  • SGI Code: SGI Adress: 8350 Allison Ave Indianapolis IN
  • Shenandoah Growers Code: SHEN Adress: 4001 West Minnesota Street, Suite 200 Indianapolis IN
  • Spartan Warehouse & Distribution Company Code: SPART Adress: 3333 Mesilla Ct. Indianapolis IN
  • Stanley Black and Decker Code: STANLEYB Adress: 501 W. New Road Greenfield IN
  • Stratosphere Quality, LLC Code: STRATOS Adress: 12024 Exit 5 Parkway Fishers IN
  • Sunright America, Inc. Code: SUNRIGHT Adress: 6205 South International Drive Columbus IN
  • Superior Metal Technologies LLC Code: SUPMETAL Adress: 9850 E. 30th St. Indianapolis IN
  • Sur La Table Code: SURLA Adress: 901 E Northfield Drive Brownsburg IN
  • Telamon Corp Code: TELAMON Adress: 1000 E 116th St Carmel IN
  • Thermal Structures, Inc. Code: THER Adress: 2800 Airwest Blvd Plainfield IN
  • Tridien Medical Code: TRIDIEN Adress: 9901 Kincaid Drive, Suite 200 Fishers IN
  • Trinity Metals LLC Code: TRINITY Adress: 6400 English Avenue Indianapolis IN
  • United Hospital Services, LLC. Code: UNIHOSP Adress: 9948 Park Davis Dr. Indianapolis IN
  • Venture Logistics Code: VENTURE Adress: 7901 W. 21st St. Indianapolis IN
  • Westcon Group, Inc Code: WESTCON Adress: 595 Perry Road Plainfield IN
  • AEL SPAN Code: AELS Adress: 6712 Grade Lane #509 Louisville KY
  • Bloemer Food Sales Code: BLOEMER Adress: 925 S 7th Street Louisville KY
  • BrightPoint Services, LLC. Code: IMMI-KY Adress: 6001 Global Distribution Way Louisville KY
  • CloudBlue Tech., Inc. Code: CLOUDBLUE-KY Adress: 1135 Aviation Rd. Hebron KY
  • Ingram Micro/Levi Code: IMMIL Adress: 6001 Global Distribution Way Louisville KY
  • Neill-LaVielle Supply Code: NEILL Adress: 1711 S. Floyd St. Louisville KY
  • Solutions 2 Go/Accion Code: SOLU2G Adress: 5000 Commerce Crossings Louisville KY
  • Tempur Sealy International, Inc Code: TEMPUR Adress: 1000 Tempur Way Lexington KY

• Nature of Business: (For example, if you work at Microsoft, then the nature of your business is software. If you work at a restaurant, the nature of your business is food services.)

EMPLOYEE INFORMATION

• Last Name / First Name

• ***SSN: (Only the last four digits) XXX-XX-0000

• Sex:

  Female

  Male

  Unknown

• Employee Address (Street, City, State and Zip)

• Date of Birth: (MM/DD/YYYY)

• Date of Hire at Client: (MM/DD/YYYY)

• Employee Phone:

• Employee Job Title:

  Select General Labor Forklift drivers Warehouse Associate Warehouse pick/pack Picker Packer Manufacturing Maintenance Administrative Cleaning Quality control General Assembly Landscaping Line Attendant Line Lead Machine Operator Maintenances Tugger Operator other

  • General Labor
  • Forklift drivers
  • Warehouse Associate
  • Warehouse pick/pack
  • Picker
  • Packer
  • Manufacturing
  • Maintenance
  • Administrative
  • Cleaning
  • Quality control
  • General Assembly
  • Landscaping
  • Line Attendant
  • Line Lead
  • Machine Operator
  • Maintenances
  • Tugger Operator
  • other

• Shift:

  First (Morning)

  Second (Evening)

  Third (Mixed)

INFORMATION ABOUT THE CASE

• Date and Time of Injury or Illness :

  Date

• 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

• 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.

  Date

• HOW DID THE ACCIDENT HAPPEN?

• Describe the sequence of events and include any relevant objects or substances.

• Add media

  Media

• Was PPE (Personal Protective Equipment) used?

  Yes

  No

  N/A

• What type:

• Root cause:

• Corrective action:

• Were there any witnesses to the accident?

• Witness Name:

• Witness Title:

• Witness Phone:

MEDICAL TREATMENT

• Did the injured employee seek medical treatment?

  Yes

  No

  N/A

• If so, what type of medical treatment did the employee seek?

  Minior medical treatment by employee

  Minior medical treatment by clinic/hospital

  Emergency Care

  Hospitalization for mor than 24 hours

• If known, what is the name of the Clinic or Hospital employee was first treated?

COMPLETED BY:

• Last Name / First Name:

• Phone:

• Signature:

  Sign

• Send Injury and Illness Report in PDF to: Injuryreports@moralesgroup.net