Report Claim / Incident

Tell us what happened

If you are a MBSIG member submitting a claim, please complete the form below.

INCIDENTS AND CLAIMS SHOULD BE REPORTED WITHIN 24 HOURS OF ACCIDENT

ACCIDENT INFORMATION
*Member Agency/Employer Name:
Phone:
Fax:
Employee Name:
DOB:
Home Address:
Home Phone:
Job Title:
Date of Hire:
Salary:
Supervisor:
Date of Accident:
Accident Cause:
Accident Location:
Description of Accident: [Please do not include sensitive Subscriber information, such as Social Security Numbers, in this form. This form can be viewed by a third party while in transit.]
What area of body was Injured?
Names of Witnesses:
Date Injury Reported:
Has the Employee Lost Time from Work?
1st Day:
5th Day:
Has Employee returned to work?
Date Employee returned to work:
Has Medical Treatment been sought?
When was first treatment?
Name and Address of Medical Provider:
Medical Provider Phone Number:
Diagnosis:
Is Light Duty available?
Treatment Plan:
Completed by:
Date:
Confirmation to be sent to email address:

*Items with an asterisk(*) are required fields.