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Please fill the form to it's entirty if possible. A Claims Advocate will review and be in touch shortly.
Submitter Information
Name
*
Company
*
Phone Number
*
Email Address
*
Incident Information
Injured Person's Name
*
Injured Person's Phone Number
*
Date of Injury
*
+
Date You Were Notified of the Injury
*
+
Location of Injury (Project or Facility Name, OR Street Address)
Incident Description
Primary Body Part Injured
*
Multiple
No Injury
Abdomen
Ankle
Arm
Back
Buttocks
Chest
Ear
Elbow
Eye
Face
Finger
Foot
Forearm
Forehead
Groin
Hand
Head
Hip
Knee
Leg
Neck
Nose
Pelvis
Shin
Shoulder
Teeth
Thigh
Toe
Trunk
Wrist
Primary Injury Type
*
No Injury
N.O.C.
Amputation
Back Strain
Break
Bruising
Burn
Contusion
Crushing
Dislocation
Exhaustion
Foreign Body
Fracture
Heart Attack
Hernia
Impale
Inhalation
Irritation
Laceration
Multiple
Muscle Pull
Poison
Puncture
Rupture
Seizure
Severe
Sprain
Strain
Swelling
Tear
Medical Treatment Necessary?
Yes
No
First Aid
Brought to Medical Facility
Was it Reported to OSHA?
Yes
No
Not Sure
Recordable in your OSHA 300 Log?
Yes
No
Not Sure
Did the Employee miss work?
Yes
No
3rd Party Potential Involvement?
Yes
No
Unknown
Attachments (C2, C3, Supervisor Form, Witness Forms, Photos, Voice Recording, Video, etc)
You can always submit documents by email, or in your Navigator Risk system later.
File 1
File 2
File 3
File 4
File 5
File 6
Incident Source
*
Choice A
Choice B
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