Incident Transmittal Form

Last Report Generated (click to view or download)

        Incident Summary Information
  Incident Overview  

  Claimant Last Name : Doe

  FROL_ID Number : 1264752

  Site Code : SC - 1

  Employer :
     Your Company
     123 Example Drive
     Anywhere NY 12345
     FEIN : 20 215377

  Injury :
     Date : 03/03/2012
     Report Number : 1 2012
     Accident State : 
     Occur on premises? : No
     Reported by : 
     Nature of injury : Sprain
     Part of body : Not Defined (left side)
Incident Description

Hurt his back

Incident Transmittal History

This incident has not been previously transmitted.

Incident Transmittal Instructions

1 Click on one of the arrow icons in the gray "Incident Summary" section header above to display the "Incident Overview". Review the information for completeness and accuracy.
2 Complete the "Incident Transmittal Details" form fields below. Fields with a red border are required.
3 Click the Next button at the bottom of the form to choose a transmittal action. Choose Transmit to complete the process and send the transmittal package to the Care Center. Choose Report if you want only to create a transmittal package and do not want to send the package to the Care Center.
4 When the process is complete you will return to the incident form. You can then go to "Last Report Generated" to get a copy of the transmittal package.

Incident Transmittal Details

 Customer Number
 Contact Name Test Sender
 Contact Phone 888578140
 Contact Email
 Employee's Employment Status
 Employee losing time from work?
 Employee's Weekly Wage
 Employee's Supervisor Name Joe Smith
 Employee's Supervisor Phone 5555555555
Transmittal Comment (300 characters max)

        Report History
Report History (click to view or download)