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Email Address:*
Injured Employee Information
Last Name:*
First Name:*
Middle Initial:
Social Security Number:*
Home Phone:*
Date of Birth (mm/dd/yyyy):*
Does the Employee Speak English?:*
If No, Specify Language:
Race:*
Mailing Address:*
City:*
State:*
Zip Code:*
County:*
Marital Status:*
Number of Dependent Children:*
Spouse's Name:
Provider Information
Doctor's/Hospital Name:
Mailing Address (Street or P.O. Box):
City:
State:
Zip Code:
Date of Injury (mm/dd/yyyy):*
Time of Injury (ex: 02:30pm):*
Date Lost Time Began (mm/dd/yyyy):*
Nature of Injury:*
Part of Body Injured or Exposed:*
How and Why Injury/Illness Occurred:*
Was employee doing his regular job?:*
Worksite Location of Injury (stairs, dock, etc.):*
Address Where Injury or Exposure Occurred (If incident occurred on a business site, include business name):
City:
State:
Zip Code:
Cause of Injury (fall, tool, machine, etc.):*
List Witnesses:*
Return to Work date/or expected (mm/dd/yyyy):*
Did Employee die?:*
Supervisor's Name:*
Date Reported (mm/dd/yyyy):*
Date of Hire (mm/dd/yyyy):*
Was employee hired or recruited in Texas?:*
Length of Service in Current Position (Months and Years):*