Alliance HR – Workers' Comp Incident Report

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Claims must be reported within 24 hours of the incident. Delayed reporting may affect benefits eligibility. If this is an emergency, call 911 first.

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Branch & Client Information

Who is reporting this incident

Branch Name *

Branch Location *

Client / Host Employer *

Date of Injury / Incident *

Date Reported *

Claim Type *

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Associate Information

The injured employee's details

Last Name *

First Name *

SSN (Last 4 digits) * For security, only last 4 digits required here.

Phone / Cell *

Position / Job Title *

Email Address

First Day on Assignment *

Written Job Description on File?

Yes No

If yes, attach with this report.

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Supervisor & Facility

Worksite and supervisor details

Facility Name *

Supervisor's Name *

Facility Address *

Supervisor's Phone *

Supervisor's Email *

Time of Injury / Incident *

Associate's Shift Start Time *

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Incident Description

What happened and how

Was the associate performing their assigned job duties? *

Yes No

Explain why not performing assigned duties *

Where specifically did the injury occur? *

What specific task was the associate performing? *

Were any tools, equipment, or chemicals involved?

Yes No

List all tools, equipment, or chemicals *

If chemicals: Is there a Safety Data Sheet (SDS)?

Yes (attach with report) No N/A

Describe in detail how the injury occurred *

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Witness Information

Were there any witnesses to this incident?

Were there any witnesses to this incident? *

Yes No

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Upon submission, an automated witness verification email will be sent to the witness at the address provided below, asking them to confirm their account of the incident.

Witness #1

Witness Full Name *

Phone Number *

Email Address (for verification) *

Address

Did witness see the incident?

Yes No

Any relation to associate?

No Yes

Where were they at time of incident?

Where did the incident happen (their account)?

Witness statement – describe exactly what happened

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Preventive Measures

To be completed by Worksite Manager

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In an effort to improve workplace safety and prevent similar injuries, describe the corrective or preventive actions your team will implement as a result of this incident.

New procedures or actions to be implemented *

Worksite Manager Name *

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Attach Documents & Photos

Supporting documentation for this claim

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Attach any relevant documents: photos of the injury/scene, job description, Safety Data Sheets (SDS), medical reports, or any other supporting materials.

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Click to browse or drag & drop files here

Accepted: JPG, PNG, PDF, DOC, DOCX | Max 10MB per file

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One-Time Medical Authorization

Workers' compensation medical release

Medical Authorization Type

Work Injury Treatment Compensability Evaluation Drug & Alcohol Screening

Authorized By

Authorization Expires

Workers Compensation Claims Administration: Next Level Administrators | P.O. Box 1061, Bradenton, FL 34206 | 877-306-6398

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Review Summary

Confirm the information before signing

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Associate Signature & Authorization

Medical records release & fraud notice

I hereby authorize the release of any and all medical, hospital, vocational and psychological records and other information related to my injury, illness or worker's compensation claim to Alliance HR LLC, its employees, agents and authorized representatives. I understand that all information released will be handled confidentially and in accordance with all applicable laws. This authorization shall stay in effect until the closure of the claim file.

COMPANY will make available Temporary Modified Duty when possible. If released by your physician to return to work on Temporary Modified Duty or without restriction, you are required to inform Human Resources.

⚠ FRAUD NOTICE: Any person who knowingly makes a false or fraudulent statement for the purpose of receiving or denying Workers' Compensation benefits or payments can be charged with a felony offense which may include incarceration and fines.

Associate Signature *

Completed By (Print Name) *

Title *

Submission Date

Worksite Manager Signature

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Upon submission, this report will be emailed to [email protected] and a copy will be sent to the supervisor. Alliance HR will file the claim with the insurance carrier. Witness verification emails will also be sent automatically.

Workers' Compensation Incident Report

Witness #1

Report Submitted Successfully

What Happens Next