Employee Information

Please complete the following form if you have a work related injury or exposure. A member of the benefits department will reach out within 24 business hours. Please note: additional forms and/or action might needed depending on the state in which the incident occured as well as the sevarity of the incident.

Please choose your line of service. *

First Name *

Last Name *

Mailing Address *

City, State, Zip *

Email Address *

Date of Birth * +

Phone Number *

Job Title *

Accident/Injury Information

In what state did the incident occur? *

Time work began: *

Date of Incident: * +

Time of Incident: *

Did you miss any shifts outside of the shift when the incident occurred? *

Yes

No

Not yet decided

Date lost time began: * +

Please list all shifts (including anticipated ones) that were missed: *

Have you returned to work? *

Yes

No

Date returned to work: +

Address where incident occurred: *

City, State, Zip *

Worksite location of incident: *

Body part affected by incident (be specific with right/left, which finger or toe) *

Type of incident: *

If other, explain: *

Cause of incident: *

Describe how & why incident occurred: *

Were there any witnesses to the incident? *

Yes

No

Witness name & phone number *

Employee Information

Initial treatment: *

Treating Healthcare Professional: *

Name of facility where treatment was rendered: *

Address of facility where treatment was rendered: *

City, State, & Zip of facility where treatment was rendered: *

Do you need or plan to seek medical treatment? *

Yes

No

Will you be needing additional/follow up care? *

Yes

No

Please explain the need for follow up care: *

Please upload any applicable documents such as facility incident report, physicians' notes, etc.

By signing this document, I attest that the information I have provided to be true to the best of my ability. I also recognize that filing a workers' compensation claim is not a guarantee of benefits being approved. While Health Carousel will assist you as much as possible during this process, any decisions about approved medical and/or indemnity is at the discretion of the carrier. *

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Date Completed * +