Incident Transmittal Form

Last Report Generated (click to view or download)

Incident Transmittal History

This incident has not been previously transmitted.

Employer Information
 Customer Number
 Policy Number
 Employer Name
 Employer Address
 Employer City/State/Zip
 Employer FEIN
 ID Code Description
 ID Code Value

Transmittal Information
 Contact Name
 Contact Phone
 Contact Email
Transmittal Comment (300 characters max)

Claimant Information
 Claimant Last Name

Incident Information
 FROL ID Number
 Date Of Incident
 Employer's Report Number
 Accident State
 Occur On Premises?
 Reported By
 Nature Of Injury
 Part Of Body
Injury Description

        Report History
Report History (click to view or download)