GL Claim Form



East-Coast---Color
GL Report Form

Reported By
Reported By Phone No
Reported By Email

Employer Name
Address
City
State
Zip
Phone
FEIN

Employee Name
Employee Email
Address
City
State
Zip
SSN
Phone
Gender
Marital Status
Number of Dependents
Date of Birth
Date of Hire
Department
Occupation
Supervisor Name
Pay Type
Employee Status

Confirm Employee Name
Date of Injury
Time of Injury
Injury on Premises
Injury Location Address
City
State
Zip
Date Employer Notified
Time Employee Began Work
Work Shift
Description of Injury
Type of Injury (Contusion,Laceration, Sprain, etc)
AND How Injury Occurred
Part of Body
Type of Medical Treatment Given
Employee miss days of work
First Date Missed
Full Pay for Day of Injury
Employee returned to work
Date Employee returned

Police or Fire Dept Contacted?
Premise: Insured is
Premise Owner Name
Premise Owner Address
Premise Owner Phone
Type of Premise
Products: Insured Is
Manufacturer’s Name
Manufacturer’s Address
Manufacturer’s Phone
Type of Product

Name of Treatment Facility
Treating Physician
Facility Phone Number
Facility Address
Facility City
Facility State
Facility Zip

Witness Name
Phone Number
Address
City
State
Zip

 

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