First Report Of Injury


eyeglasses online

Important - Please Note:

  • This form will not submit properly if you have Internet Explorer 4, 5 or 6
  • All text fields colored green/aqua are required.
    • If you are sent back to this form after you click "Submit", you most likely left out some required information.
    • Look through the entire form for red text which reads similar to: "'Legal Name' is required." and add information to the field.
  • If you use IE 9, please TAB between fields.
  • You must have cookies enabled for
  • You will have a chance to print the form after you hit submit.
    • Do not try to print the page before submitting.

    Employer Section

    Employee Section

    Accident Section

    Injury Section

    Insurance Section