24 Hour Notification of Employee Accident or Injury

If you need immediate assistance from your claim manager, call (206) 812-3850.

For security reasons, only minimal information about the incident is collected.

The intent of this form is for NOTIFICATION to your claim manager and has no other purpose.

After completing the required data entry fields, you will NOT be able to print a First Report of Accident or Injury. If you need a copy of the report please call your claim manager during business hours. There are no options to view, edit or correct data once the submit button has been clicked. If you make an error, resubmit the incident.

All submittals are reviewed prior to acceptance. Your claim manager will contact you by phone to obtain any additional information that may be required.