This section must be completed by either the employee, medical provider, or employer.
* indicates a required field.
Employee Details
Employee's First Name *:
Employee's Last Name *:
Social Security Number *:	(no dashes)
Date of Birth *:	mm/dd/yyyy
Gender:	Female Male
Marital Status:	Single Married
Employee's Telephone Number:	999-999-9999x999
Employee's Physical Address *:
City *:
State/Province *:	Alabama Alberta Alaska Arizona Arkansas British Columbia California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada Newfoundland New Brunswick New Hampshire New Jersey New Mexico New York North Carolina North Dakota Novia Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington DC
Zip/Postal Code *:	99999-9999 or X9X 9X9
Employee's Mailing Address, if different than physical address:
City, if different than physical address:
State/Province, if different than physical address:	Alabama Alberta Alaska Arizona Arkansas British Columbia California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada Newfoundland New Brunswick New Hampshire New Jersey New Mexico New York North Carolina North Dakota Novia Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington DC
Zip/Postal Code:	99999-9999 or X9X 9X9
Date of Injury *:	mm/dd/yyyy
Time of Injury:	hh:mm AM PM
Body Part Injured (Example: Left 2nd/middle finger, right shoulder, left ankle.) *:	Delete Body Part Location Primary
Nature of the injury or illness? (Example: chemical burn left hand, broken left leg, carpal tunnel syndrome in left wrist, etc.) *:	No Physical Injury AIDS Adverse reaction to a vaccination or inoculation All Other Cumulative Injuries, NOC All Other Occupational Disease Injury, NOC All Other Specific Injuries, NOC Amputation Angina Pectoris Asbestos Asphyxiation Black Lung Burn Byssinosis COVID-19 Cancer Carpal Tunnel Syndrome Concussion Contagious Disease Contusion Crushing Dermatitis Dislocation Dust Disease, NOC Electric Shock Enucleation Exposure to Bodily Fluid Foreign Body Fracture Freezing Hearing Loss or Impairment (Traumatic) Heat Prostration Hepatitis C Hernia Infection Inflammation Lacerations Loss of Hearing (Progressive) Mental Disorder Mental Stress Multiple Injuries Including Both Physical and Psychological Multiple Physical Injuries Only Myocardial Infarction Needle Stick No Physical Injury Poisoning - Chemical, (Other Than Metals) Poisoning - General (Not OD or Cumulative Injury) Poisoning - Metal Puncture Radiation Respiratory Disorders Rupture Severance Sillcosis Sprain Strain Syncope (Fainting) VDT-Related Disease Vascular Vision Loss
How did the injury happen (400 character max)? *:
Has this claim been filed in another state? *:	Yes No
Where did the injury happen? (City) *:
County:
State *:	Alabama Alberta Alaska Arizona Arkansas British Columbia California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada Newfoundland New Brunswick New Hampshire New Jersey New Mexico New York North Carolina North Dakota Novia Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington DC
Medical Details
Have you received treatment for the injury? *	Yes No
Treating Doctor's Name:
Date of First Treatment :	mm/dd/yyyy
Clinic/Hospital Name :
Emergency Room Visit :	YesNo
Clinic/Hospital Telephone Number:	999-999-9999x999
Mailing Address:
City :
State/Province :	Alabama Alberta Alaska Arizona Arkansas British Columbia California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada Newfoundland New Brunswick New Hampshire New Jersey New Mexico New York North Carolina North Dakota Novia Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington DC
Zip/Postal Code:	99999-9999 or X9X 9X9
	Include additional providers in to the "Additional Information" section.
Employer Details
Employer's Name *:
Employer's Phone Number *:	999-999-9999x999
Employer's Mailing Address:
City:
State/Province:	Alabama Alberta Alaska Arizona Arkansas British Columbia California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada Newfoundland New Brunswick New Hampshire New Jersey New Mexico New York North Carolina North Dakota Novia Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington DC
Zip:	99999-9999 or X9X 9X9
What is the Employee's job? *:
Date Hired:	(Month) Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec  (Year) *
Last day worked in North Dakota prior to injury *:	mm/dd/yyyy
Who is filling out this form (check all that apply) *:	Employee   Employer