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Claim Kit

Your Company Information

Employee Identifying Information

Accident Detail

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Hospital, Urgent care, Doctor information

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Witness Information & Statement


I, the undersigned witnessed or am reporting the injury by personal observation or reported by the listed witness, and I do hereby affirm that each and every declaration I’ve made in the above-referenced report of injury or illness is true and correct to the best of my ability. I further affirm I have made the declarations of my own free will, without coercion, promises or enticements of any type. I voluntarily present this information, and with this authorization, hold harmless any recipient of the information who uses or shares the information in any way. I know that any falsification of information herein may result in a criminal matter and that any person who knowingly presents a false statement for the fraudulent payment of a loss is guilty of a crime, and may be subject to fines and confinement in a state prison.

Authorized Representative