Information
-
Date and Time
-
Prepared By
Restaurant Location Information
-
Unit #
-
Unit Name
-
Unit Phone #
-
Address
-
City
-
State
-
Zip Code
Incident Qualification
-
Date and Time of Incident
-
Date and Time Operator was notified
-
Name of individual reporting incident
-
Title
-
Phone #
Claimant Information
-
Social Security #
-
First Name
-
Middle Initial
-
Last Name
-
Home Phone #
-
Work Phone #
-
Address
-
City
-
State
-
Zip Code
-
Date of Birth
-
Male or Female
-
Marital Status
- Single
- Married
- Divorced
- Seperated
- Widowed
- Unknown
-
Number of Dependants
-
Employee's Title
-
Status
-
Full/Part Time
-
Date of Hire
-
Date of Termination
-
Wage Amount
-
Frequency
-
Average Hours per day
-
Supervisor's Name
-
Supervisor's Title
-
Supervisor's Phone #
Incident Information
-
Details of Incident
-
Will team member miss work as result of injury?
-
Last Date Worked
-
Salary Continued?
-
Date Returned to Work
-
Received Full Wages?
-
Incident Location
-
Address
-
City
-
State
-
Zip
