EMPLOYER’S REPORT OF INJURY (SHORT FORM) (MAISL)



EMPLOYER’S REPORT OF INJURYshort form Email, fax, or mail to:MML Fund Claims3196 Kraft Avenue S.E. Suite 206 Grand Rapids MI 49512-2065 Fax: 616-649-1796Email: gr.mml@OSHA LOG CASE # FORMTEXT ?????* * THIS REPORT MUST BE COMPLETED AND SIGNED BY THE EMPLOYER * *EMPLOYEEFull Name (First, Middle Initial, Last) FORMTEXT ?????Soc Sec No. FORMTEXT ????? FORMCHECKBOX Male FORMCHECKBOX FemaleStreet FORMTEXT ?????City FORMTEXT ?????State FORMTEXT ?????Zip FORMTEXT ?????Employee Telephone ( FORMTEXT ?????) FORMTEXT ?????Date of Birth FORMTEXT ?????Marital Status FORMTEXT ?????Dependents FORMTEXT ?????Occupation FORMTEXT ?????Employee Department FORMTEXT ?????Date of Hire FORMTEXT ?????INJURYDate of Injury FORMTEXT ?????Time of Injury FORMTEXT ????? FORMCHECKBOX AM FORMCHECKBOX PMTime employee began work FORMTEXT ????? FORMCHECKBOX AM FORMCHECKBOX PMCity + ZIP CODE Where Injury Occurred FORMTEXT ?????What kind of injury? (contusion, cut, fracture, sprain, strain, etc.) FORMTEXT ?????Body Part Injured FORMTEXT ?????How did injury occur? FORMTEXT ????? FORMTEXT ?????What was employee doing just before incident occurred? FORMTEXT ????? FORMTEXT ?????Did Employee Die FORMCHECKBOX Yes FORMCHECKBOX NoLast Day Worked FORMTEXT ????? FORMCHECKBOX No Time LostDate Returned to Work FORMTEXT ?????If yes, what date? FORMTEXT ?????MEDICALWas employee treated in an Emergency Room? FORMCHECKBOX Yes FORMCHECKBOX NoWas employee hospitalized overnight as an in-patient? FORMCHECKBOX Yes FORMCHECKBOX NoCase No. from Hospital Log FORMTEXT ?????Physician/Clinic FORMTEXT ?????Address FORMTEXT ?????Telephone ( FORMTEXT ?????) FORMTEXT ?????Hospital FORMTEXT ?????EMPLOYERFull Business Name FORMTEXT ?????Federal ID# (Required by BWC) FORMTEXT ?????Mailing Address FORMTEXT ?????Location FORMTEXT ?????Address of Accident Location (if different from mailing address) FORMTEXT ?????Contact FORMTEXT ?????Telephone ( FORMTEXT ?????) FORMTEXT ?????Date Injury Was Reported to Employer FORMTEXT ?????Please return to MEADOWBROOK CLAIMS SERVICE3196 Kraft SE, Suite 206, Grand Rapids, MI 49512-2065(800) 752-7477 Phone, (616) 649-1796 Fax FORMTEXT ????? FORMTEXT ?????Preparer’s Signature (Employer)DatePreparer’s Name (Please Print)Preparer’s Title (Please Print) ................
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