Team Member Injury form

Team members injured on the job must complete and submit the injury/illness form. This information may be used for OSHA and workers compensation reporting.

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Please check one
Date and Time of Injury
Name (first, middle initial, and last)
Address
Home Hospital Name
Is this where the injury happened?
Were you working at your regular job when you were injured?
Employment:
Do you have a set schedule or random?
Date and time you reported your injury to your supervisor/manager:
Have you had any other worker's compensation claims in the past?
Will you be seeking medical treatment?
Do you need follow up visits or other forms of treatment (if known)?
Was safety equipment available?
Was the injury a result of a bite or scratch?
Was this a sharps injury (needle, surgical blade, etc.)?

Injured team members seeking medical treatment must file a Claim with Traveler’s at 800-238-6225 or file the claim online, via www.travelers.com   Policy Number: UB2T358196 and email claim # and form to Partner’s People Operations Department.

Was a claim filed?