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Request Service
(866) 314-4443
24/7 Emergency Service
Serving Lake, Sumter, Citrus, Marion, Hernando, Levy, and Alachua.
Employee Injury Form
Employee Name
(Required)
Today's Date
(Required)
Are you filling out this form for yourself?
(Required)
Yes
No
If No, Name of Representative Completing Form
(Required)
Name of Supervisor
(Required)
Date of Injury
(Required)
Time of Injury
(Required)
Hours
:
Minutes
AM
PM
AM/PM
Location of Injury
(Required)
Which medical facility will perform an examination?
(Required)
Have you informed your supervisor of the injury/incident?
(Required)
Yes
No
Describe your incident
(Required)
Provide as much detail as possible, including dates, times, names, etc. Be very specific.
Please upload photos and documentation
Drop files here or
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Max. file size: 5 MB, Max. files: 5.
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