Report an Incident Have you sustained an injury? Please use the form below to provide some preliminary information about the incident. A member of our team will follow up with you soon to discuss and send you the necessary documents to complete. Who was injured?(Required) First Last Who is their employer?(Required) Email Number(Required)What is the address of the location where the incident occurred? Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State What type of injury was sustained?(Required) Where on the body was the injury sustained?(Required) Please describe what you were doing when the injury occurred.(Required)CAPTCHA
