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Submitted URL: https://bit.ly/ReportWCClaim
Effective URL: https://live.origamirisk.com/Origami/LossEvents/New?_collectionLinkItemID=3&LossEventTypeID=10&noSnapshot=true
Submission Tags: falconsandbox
Submission: On September 11 via api from US — Scanned from CA
Effective URL: https://live.origamirisk.com/Origami/LossEvents/New?_collectionLinkItemID=3&LossEventTypeID=10&noSnapshot=true
Submission Tags: falconsandbox
Submission: On September 11 via api from US — Scanned from CA
Form analysis 1 forms found in the DOM
POST /Origami/LossEvents/save
<form action="/Origami/LossEvents/save" enctype="" id="entryForm" method="post">
<input name="__RequestVerificationToken" type="hidden" value="qRkhE98cL5CjIWeYqXbZBVNgLDnyzUzM4B3g5iyV1fewfcLL3v802Wexk-m8XZX0hMcEaskiv78rQUooBBFkj1YaLvlaCe-pMGanJAg0DLoFNZHeY7eZbn7ktfRRNveqn2wcsgadi4CnMAYterFDtw2"
aria-label="__RequestVerificationToken">
<input name="_OrigamiExternalAccessToken" type="hidden" value="" aria-label="_OrigamiExternalAccessToken">
<input name="_BypassRating" type="hidden" value="false" aria-label="_BypassRating">
<input name="_CollectionLinkItemID" type="hidden" value="3" aria-label="_CollectionLinkItemID">
<input name="_OrigamiFormSetID" type="hidden" value="" aria-label="_OrigamiFormSetID">
<input name="_ConcurrentLockID" type="hidden" value="" aria-label="_ConcurrentLockID">
<input name="_ValuePeriodStartDate" type="hidden" value="" aria-label="_ValuePeriodStartDate">
<input name="_DelayedAutoFillTokens" type="hidden" value="" aria-label="_DelayedAutoFillTokens">
<input name="_SurveyDataCollectionResultIDs" type="hidden" value="" aria-label="_SurveyDataCollectionResultIDs">
<input name="_SurveyDataValidationResultIDs" type="hidden" value="" aria-label="_SurveyDataValidationResultIDs">
<input name="_UserAssignedActionID" type="hidden" value="0" aria-label="_UserAssignedActionID">
<input name="_DomainRecordTemplateID" type="hidden" value="" aria-label="_DomainRecordTemplateID">
<input name="_DomainRecordTemplateSourceRecordID" type="hidden" value="" aria-label="_DomainRecordTemplateSourceRecordID">
<input name="_LoadTime" type="hidden" value="638616694064179307" aria-label="_LoadTime">
<input name="_isInitiatedFromCard" type="hidden" value="" aria-label="_isInitiatedFromCard">
<input id="CachedGridKeys" name="CachedGridKeys" type="hidden" value="" aria-label="CachedGridKeys">
<input name="_searchList" type="hidden" value="" aria-label="_searchList">
<input name="_searchList_NextRecordURL" type="hidden" value="" aria-label="_searchList_NextRecordURL">
<input name="_searchList_NextPageURL" type="hidden" value="" aria-label="_searchList_NextPageURL">
<input name="_searchList_ReturnToSearch" type="hidden" value="" aria-label="_searchList_ReturnToSearch">
<div id="AllContent">
<div class="panel-contents" data-panel-key-desc="(Panel Key: EditFormPanel)">
<div class="hidden">
<input class="autoHiddenField" type="hidden" name="MemberID" value="" aria-label="MemberID">
<input class="autoHiddenField" type="hidden" name="incidentTypeID" value="" aria-label="incidentTypeID">
<input class="autoHiddenField" type="hidden" name="withIncidents" value="" aria-label="withIncidents">
<input class="autoHiddenField" type="hidden" name="fromIncidentID" value="" aria-label="fromIncidentID">
<input class="autoHiddenField" type="hidden" name="fromClaimID" value="" aria-label="fromClaimID">
<input class="autoHiddenField" type="hidden" name="RiskUnit" value="" aria-label="RiskUnit">
<input id="Origami_ModifiedDateTicks" name="Origami.ModifiedDateTicks" type="hidden" value="0" aria-label="Origami_ModifiedDateTicks">
<input id="Origami_SessionKey" name="Origami.SessionKey" type="hidden" value="AccountID=12314;ClientID=10001;UserID=15712" aria-label="Origami_SessionKey">
<input type="hidden" name="newPolicySnapshotID" value="">
</div>
<div class="origamiform LossEvent_NewForm " data-inputnameprefix="" data-domainname="LossEvent">
<div class="origamiformidentifier hidden" data-formrepoidsnolog="10832"></div>
<div aria-labelledby="title_WorkersCompensation-FirstReportofInjury" class="panel" role="region">
<h3 id="title_WorkersCompensation-FirstReportofInjury" tabindex="-1">Workers Compensation - First Report of Injury</h3>
<div>
<div class="section">
<ul class="properties wideLabels ">
<li class="required" for="CustomText1" label="Policy Number"><label class="required" for="CustomText1" title="Policy Number. Required field.">Policy Number: </label><span class="value"><input aria-label="Policy Number"
aria-required="true" class="formulaField medium textInput" id="CustomText1" maxlength="256" name="CustomText1" type="text" value=""></span></li>
<li class="hidden" for="Alias_LossEvent_IntakeCode" label="Intake Code"><label for="Alias_LossEvent_IntakeCode">Intake Code: </label><span class="value"><input id="CustomCode4ID" name="CustomCode4ID" type="hidden" value="17356"
aria-label="CustomCode4ID"></span></li>
<li class="hidden" for="LossEventType" label="Loss Event Type"><label for="LossEventType">Loss Event Type: </label><span class="value"><input id="LossEventTypeID" name="LossEventTypeID" type="hidden" value="10"
aria-label="LossEventTypeID"></span></li>
<li class="required" for="CustomCode7ID" label="Jurisdiction"><label class="required" for="CustomCode7ID" title="Jurisdiction. Required field.">Jurisdiction: </label><span class="value"><select aria-label="Jurisdiction"
aria-required="true" class="medium faded" data-codetypeid="10002" data-fieldtype="Code" id="CustomCode7ID" name="CustomCode7ID">
<option value="" class="faded">- None Selected -</option>
<option value="10164" style="color: initial;">Alabama</option>
<option value="10163" style="color: initial;">Alaska</option>
<option value="10166" style="color: initial;">Arizona</option>
<option value="10165" style="color: initial;">Arkansas</option>
<option value="10167" style="color: initial;">California</option>
<option value="10168" style="color: initial;">Colorado</option>
<option value="10169" style="color: initial;">Connecticut</option>
<option value="10171" style="color: initial;">Delaware</option>
<option value="10172" style="color: initial;">Florida</option>
<option value="10173" style="color: initial;">Georgia</option>
<option value="10174" style="color: initial;">Hawaii</option>
<option value="10176" style="color: initial;">Idaho</option>
<option value="10177" style="color: initial;">Illinois</option>
<option value="10178" style="color: initial;">Indiana</option>
<option value="10175" style="color: initial;">Iowa</option>
<option value="10179" style="color: initial;">Kansas</option>
<option value="10180" style="color: initial;">Kentucky</option>
<option value="10181" style="color: initial;">Louisiana</option>
<option value="10184" style="color: initial;">Maine</option>
<option value="10183" style="color: initial;">Maryland</option>
<option value="10182" style="color: initial;">Massachusetts</option>
<option value="10185" style="color: initial;">Michigan</option>
<option value="10186" style="color: initial;">Minnesota</option>
<option value="10188" style="color: initial;">Mississippi</option>
<option value="10187" style="color: initial;">Missouri</option>
<option value="10189" style="color: initial;">Montana</option>
<option value="10192" style="color: initial;">Nebraska</option>
<option value="10196" style="color: initial;">Nevada</option>
<option value="10193" style="color: initial;">New Hampshire</option>
<option value="10194" style="color: initial;">New Jersey</option>
<option value="10195" style="color: initial;">New Mexico</option>
<option value="10197" style="color: initial;">New York</option>
<option value="10190" style="color: initial;">North Carolina</option>
<option value="10191" style="color: initial;">North Dakota</option>
<option value="10198" style="color: initial;">Ohio</option>
<option value="10199" style="color: initial;">Oklahoma</option>
<option value="10200" style="color: initial;">Oregon</option>
<option value="10201" style="color: initial;">Pennsylvania</option>
<option value="10202" style="color: initial;">Rhode Island</option>
<option value="10203" style="color: initial;">South Carolina</option>
<option value="10204" style="color: initial;">South Dakota</option>
<option value="10205" style="color: initial;">Tennessee</option>
<option value="10206" style="color: initial;">Texas</option>
<option value="10207" style="color: initial;">Utah</option>
<option value="10209" style="color: initial;">Vermont</option>
<option value="10208" style="color: initial;">Virginia</option>
<option value="10210" style="color: initial;">Washington</option>
<option value="10212" style="color: initial;">West Virginia</option>
<option value="10211" style="color: initial;">Wisconsin</option>
<option value="10213" style="color: initial;">Wyoming</option>
<option value="14271" style="color: initial;">American Samoa</option>
<option value="14269" style="color: initial;">Armed Forces Europe, Middle East, & Canada</option>
<option value="14270" style="color: initial;">Armed Forces Pacific</option>
<option value="14279" style="color: initial;">Canada - Alberta</option>
<option value="14280" style="color: initial;">Canada - British Columbia</option>
<option value="14281" style="color: initial;">Canada - Manitoba</option>
<option value="14282" style="color: initial;">Canada - New Brunswick</option>
<option value="14290" style="color: initial;">Canada - Northwest Territories</option>
<option value="14283" style="color: initial;">Canada - Newfoundland</option>
<option value="14284" style="color: initial;">Canada - Nova Scotia</option>
<option value="14285" style="color: initial;">Canada - Nunavut</option>
<option value="14286" style="color: initial;">Canada - Ontario</option>
<option value="14287" style="color: initial;">Canada - Prince Edward Island</option>
<option value="14288" style="color: initial;">Canada - Quebec</option>
<option value="14289" style="color: initial;">Canada - Saskatchewan</option>
<option value="14291" style="color: initial;">Canada - Yukon Territory</option>
<option value="10170" style="color: initial;">District of Columbia</option>
<option value="14292" style="color: initial;">Federal Jurisdiction</option>
<option value="14272" style="color: initial;">Federated States of Micronesia</option>
<option value="14273" style="color: initial;">Guam</option>
<option value="14274" style="color: initial;">Marshall Islands</option>
<option value="14275" style="color: initial;">Northern Mariana Islands</option>
<option value="14277" style="color: initial;">Palau</option>
<option value="14276" style="color: initial;">Puerto Rico</option>
<option value="10214" style="color: initial;">Unknown or Unspecified</option>
<option value="14278" style="color: initial;">Virgin Islands</option>
</select></span></li>
<li class="hidden" for="Alias_LossEvent_EnteredFromACL" label="Entered From ACL?"><label for="Alias_LossEvent_EnteredFromACL">Entered From ACL?</label><span class="value"><input id="CustomBool55" name="CustomBool55" type="hidden"
value="True" aria-label="CustomBool55"></span></li>
</ul>
</div>
<div class="section">
<h4 tabindex="-1">Insured Information</h4>
<ul class="properties wideLabels ">
<li for="CustomText19" label="Employer"><label for="CustomText19">Employer: </label><span class="value"><input aria-label="Employer" class="medium textInput" id="CustomText19" maxlength="256" name="CustomText19" type="text"
value=""></span></li>
<li for="CustomText21" label="Employer Street 1"><label for="CustomText21">Employer Street 1: </label><span class="value"><input aria-label="Employer Street 1" class="medium textInput" id="CustomText21" maxlength="256"
name="CustomText21" type="text" value=""></span></li>
<li for="CustomText22" label="Employer Street 2"><label for="CustomText22">Employer Street 2: </label><span class="value"><input aria-label="Employer Street 2" class="medium textInput" id="CustomText22" maxlength="256"
name="CustomText22" type="text" value=""></span></li>
<li for="CustomText23" label="Employer City"><label for="CustomText23">Employer City: </label><span class="value"><input aria-label="Employer City" class="medium textInput" id="CustomText23" maxlength="256" name="CustomText23"
type="text" value=""></span></li>
<li for="CustomCode5ID" label="Employer State"><label for="CustomCode5ID">Employer State: </label><span class="value"><select aria-label="Employer State" class="medium faded" data-codetypeid="10002" data-fieldtype="Code"
id="CustomCode5ID" name="CustomCode5ID">
<option value="" class="faded">- None Selected -</option>
<option value="10164" style="color: initial;">Alabama</option>
<option value="10163" style="color: initial;">Alaska</option>
<option value="10166" style="color: initial;">Arizona</option>
<option value="10165" style="color: initial;">Arkansas</option>
<option value="10167" style="color: initial;">California</option>
<option value="10168" style="color: initial;">Colorado</option>
<option value="10169" style="color: initial;">Connecticut</option>
<option value="10171" style="color: initial;">Delaware</option>
<option value="10172" style="color: initial;">Florida</option>
<option value="10173" style="color: initial;">Georgia</option>
<option value="10174" style="color: initial;">Hawaii</option>
<option value="10176" style="color: initial;">Idaho</option>
<option value="10177" style="color: initial;">Illinois</option>
<option value="10178" style="color: initial;">Indiana</option>
<option value="10175" style="color: initial;">Iowa</option>
<option value="10179" style="color: initial;">Kansas</option>
<option value="10180" style="color: initial;">Kentucky</option>
<option value="10181" style="color: initial;">Louisiana</option>
<option value="10184" style="color: initial;">Maine</option>
<option value="10183" style="color: initial;">Maryland</option>
<option value="10182" style="color: initial;">Massachusetts</option>
<option value="10185" style="color: initial;">Michigan</option>
<option value="10186" style="color: initial;">Minnesota</option>
<option value="10188" style="color: initial;">Mississippi</option>
<option value="10187" style="color: initial;">Missouri</option>
<option value="10189" style="color: initial;">Montana</option>
<option value="10192" style="color: initial;">Nebraska</option>
<option value="10196" style="color: initial;">Nevada</option>
<option value="10193" style="color: initial;">New Hampshire</option>
<option value="10194" style="color: initial;">New Jersey</option>
<option value="10195" style="color: initial;">New Mexico</option>
<option value="10197" style="color: initial;">New York</option>
<option value="10190" style="color: initial;">North Carolina</option>
<option value="10191" style="color: initial;">North Dakota</option>
<option value="10198" style="color: initial;">Ohio</option>
<option value="10199" style="color: initial;">Oklahoma</option>
<option value="10200" style="color: initial;">Oregon</option>
<option value="10201" style="color: initial;">Pennsylvania</option>
<option value="10202" style="color: initial;">Rhode Island</option>
<option value="10203" style="color: initial;">South Carolina</option>
<option value="10204" style="color: initial;">South Dakota</option>
<option value="10205" style="color: initial;">Tennessee</option>
<option value="10206" style="color: initial;">Texas</option>
<option value="10207" style="color: initial;">Utah</option>
<option value="10209" style="color: initial;">Vermont</option>
<option value="10208" style="color: initial;">Virginia</option>
<option value="10210" style="color: initial;">Washington</option>
<option value="10212" style="color: initial;">West Virginia</option>
<option value="10211" style="color: initial;">Wisconsin</option>
<option value="10213" style="color: initial;">Wyoming</option>
<option value="14271" style="color: initial;">American Samoa</option>
<option value="14269" style="color: initial;">Armed Forces Europe, Middle East, & Canada</option>
<option value="14270" style="color: initial;">Armed Forces Pacific</option>
<option value="14279" style="color: initial;">Canada - Alberta</option>
<option value="14280" style="color: initial;">Canada - British Columbia</option>
<option value="14281" style="color: initial;">Canada - Manitoba</option>
<option value="14282" style="color: initial;">Canada - New Brunswick</option>
<option value="14290" style="color: initial;">Canada - Northwest Territories</option>
<option value="14283" style="color: initial;">Canada - Newfoundland</option>
<option value="14284" style="color: initial;">Canada - Nova Scotia</option>
<option value="14285" style="color: initial;">Canada - Nunavut</option>
<option value="14286" style="color: initial;">Canada - Ontario</option>
<option value="14287" style="color: initial;">Canada - Prince Edward Island</option>
<option value="14288" style="color: initial;">Canada - Quebec</option>
<option value="14289" style="color: initial;">Canada - Saskatchewan</option>
<option value="14291" style="color: initial;">Canada - Yukon Territory</option>
<option value="10170" style="color: initial;">District of Columbia</option>
<option value="14292" style="color: initial;">Federal Jurisdiction</option>
<option value="14272" style="color: initial;">Federated States of Micronesia</option>
<option value="14273" style="color: initial;">Guam</option>
<option value="14274" style="color: initial;">Marshall Islands</option>
<option value="14275" style="color: initial;">Northern Mariana Islands</option>
<option value="14277" style="color: initial;">Palau</option>
<option value="14276" style="color: initial;">Puerto Rico</option>
<option value="10214" style="color: initial;">Unknown or Unspecified</option>
<option value="14278" style="color: initial;">Virgin Islands</option>
</select></span></li>
<li for="CustomText24" label="Employer Postal Code"><label for="CustomText24">Employer Postal Code: </label><span class="value"><input aria-label="Employer Postal Code" class="medium textInput" id="CustomText24" maxlength="256"
name="CustomText24" type="text" value=""></span></li>
<li for="CustomText27" label="Employer Contact Name"><label for="CustomText27">Employer Contact Name: </label><span class="value"><input aria-label="Employer Contact Name" class="medium textInput" id="CustomText27"
maxlength="256" name="CustomText27" type="text" value=""></span></li>
<li for="CustomText28" label="Employer Telephone"><label for="CustomText28">Employer Telephone: </label><span class="value"><input aria-label="Employer Telephone" class="phoneNumber medium textInput" id="CustomText28"
instructions="Enter digits for 'US' or type + for international numbers." maxlength="256" name="CustomText28" phone-defaultcountry="US" type="text" value=""> <span class="faded">ext</span> <input
aria-label="Employer Telephone Extension" class="phoneExtension medium textInput" maxlength="256" name="__phoneExt_CustomText28" type="text" value=""></span><span class="value faded instructions">Enter digits for 'US' or type +
for international numbers.</span></li>
<li class="required" for="CustomText29" label="Employer Email"><label class="required" for="CustomText29" title="Employer Email. Required field.">Employer Email: </label><span class="value"><input aria-label="Employer Email"
aria-required="true" class="medium textInput" id="CustomText29" maxlength="256" name="CustomText29" type="text" value=""></span></li>
<li class="required" for="CustomText108" label="Employer Email Verify"><label class="required" for="CustomText108" title="Employer Email Verify. Required field.">Employer Email Verify: </label><span class="value"><input
aria-label="Employer Email Verify" aria-required="true" class="medium textInput" id="CustomText108" maxlength="256" name="CustomText108" type="text" value=""></span></li>
<li for="CustomCode6ID" label="Employer Preferred Communication"><label for="CustomCode6ID">Employer Preferred Communication: </label><span class="value"><select aria-label="Insured Preferred Communication" class="medium faded"
data-codetypeid="10235" data-fieldtype="Code" id="CustomCode6ID" name="CustomCode6ID">
<option value="" class="faded">- None Selected -</option>
<option value="17945" style="color: initial;">Email</option>
<option value="17946" style="color: initial;">Phone</option>
</select></span></li>
</ul>
</div>
</div>
</div>
<div aria-labelledby="title_Employee/WageInformation" class="panel yui-g" role="region">
<h3 id="title_Employee/WageInformation" tabindex="-1">Employee/Wage Information</h3>
<div class="yui-u first">
<div class="section">
<ul class="properties wideLabels ">
<li class="required" for="CustomText14" label="First Name"><label class="required" for="CustomText14" title="First Name. Required field.">First Name: </label><span class="value"><input aria-label="Claimant First Name"
aria-required="true" class="formulaField medium textInput" id="CustomText14" maxlength="256" name="CustomText14" type="text" value=""></span></li>
<li for="CustomText33" label="Middle Name"><label for="CustomText33">Middle Name: </label><span class="value"><input aria-label="Claimant Middle Name" class="medium textInput" id="CustomText33" maxlength="256" name="CustomText33"
type="text" value=""></span></li>
<li class="required" for="CustomText15" label="Last Name"><label class="required" for="CustomText15" title="Last Name. Required field.">Last Name: </label><span class="value"><input aria-label="Claimant Last Name"
aria-required="true" class="formulaField medium textInput" id="CustomText15" maxlength="256" name="CustomText15" type="text" value=""></span></li>
<li class="required" for="Name" label="Name"><label class="required" for="Name" title="Name. Required field.">Name: </label><span class="value"><input aria-label="Name" aria-required="true" class="medium textInput"
data-origami-formula="({Alias_EventPolicy} == '' ? {Alias_Event_ClaimantFirst} + ' ' + {Alias_Event_ClaimantLast} : {Alias_Event_ClaimantFirst} + ' ' + {Alias_Event_ClaimantLast} )" id="Name" maxlength="250" name="Name"
readonly="readonly" type="text" value=""></span></li>
<li for="CustomText30" label="Suffix"><label for="CustomText30">Suffix: </label><span class="value"><input aria-label="Claimant Suffix" class="medium textInput" id="CustomText30" maxlength="256" name="CustomText30" type="text"
value=""></span></li>
<li for="CustomText2" label="Address Line 1"><label for="CustomText2">Address Line 1: </label><span class="value"><input aria-label="Claimant Address 1" class="medium textInput" id="CustomText2" maxlength="256" name="CustomText2"
type="text" value=""></span></li>
<li for="CustomText3" label="Address Line 2"><label for="CustomText3">Address Line 2: </label><span class="value"><input aria-label="Claimant Address 2" class="medium textInput" id="CustomText3" maxlength="256" name="CustomText3"
type="text" value=""></span></li>
<li for="CustomText4" label="City"><label for="CustomText4">City: </label><span class="value"><input aria-label="Claimant City" class="medium textInput" id="CustomText4" maxlength="256" name="CustomText4" type="text"
value=""></span></li>
<li for="CustomCode1ID" label="State"><label for="CustomCode1ID">State: </label><span class="value"><select aria-label="Claimant State" class="medium faded" data-codetypeid="10159" data-fieldtype="Code" id="CustomCode1ID"
name="CustomCode1ID">
<option value="" class="faded">- None Selected -</option>
<option value="16862" style="color: initial;">Alabama</option>
<option value="16861" style="color: initial;">Alaska</option>
<option value="16866" style="color: initial;">Arizona</option>
<option value="16864" style="color: initial;">Arkansas</option>
<option value="16867" style="color: initial;">California</option>
<option value="16868" style="color: initial;">Colorado</option>
<option value="16869" style="color: initial;">Connecticut</option>
<option value="16871" style="color: initial;">Delaware</option>
<option value="16872" style="color: initial;">Florida</option>
<option value="16874" style="color: initial;">Georgia</option>
<option value="16876" style="color: initial;">Hawaii</option>
<option value="16878" style="color: initial;">Idaho</option>
<option value="16879" style="color: initial;">Illinois</option>
<option value="16880" style="color: initial;">Indiana</option>
<option value="16877" style="color: initial;">Iowa</option>
<option value="16881" style="color: initial;">Kansas</option>
<option value="16882" style="color: initial;">Kentucky</option>
<option value="16883" style="color: initial;">Louisiana</option>
<option value="16886" style="color: initial;">Maine</option>
<option value="16885" style="color: initial;">Maryland</option>
<option value="16884" style="color: initial;">Massachusetts</option>
<option value="16888" style="color: initial;">Michigan</option>
<option value="16889" style="color: initial;">Minnesota</option>
<option value="16892" style="color: initial;">Mississippi</option>
<option value="16890" style="color: initial;">Missouri</option>
<option value="16893" style="color: initial;">Montana</option>
<option value="16896" style="color: initial;">Nebraska</option>
<option value="16900" style="color: initial;">Nevada</option>
<option value="16897" style="color: initial;">New Hampshire</option>
<option value="16898" style="color: initial;">New Jersey</option>
<option value="16899" style="color: initial;">New Mexico</option>
<option value="16901" style="color: initial;">New York</option>
<option value="16894" style="color: initial;">North Carolina</option>
<option value="16895" style="color: initial;">North Dakota</option>
<option value="16902" style="color: initial;">Ohio</option>
<option value="16903" style="color: initial;">Oklahoma</option>
<option value="16904" style="color: initial;">Oregon</option>
<option value="16905" style="color: initial;">Pennsylvania</option>
<option value="16908" style="color: initial;">Rhode Island</option>
<option value="16909" style="color: initial;">South Carolina</option>
<option value="16910" style="color: initial;">South Dakota</option>
<option value="16911" style="color: initial;">Tennessee</option>
<option value="16912" style="color: initial;">Texas</option>
<option value="16913" style="color: initial;">Utah</option>
<option value="16916" style="color: initial;">Vermont</option>
<option value="16914" style="color: initial;">Virginia</option>
<option value="16917" style="color: initial;">Washington</option>
<option value="16918" style="color: initial;">West Virginia</option>
<option value="16919" style="color: initial;">Wisconsin</option>
<option value="16920" style="color: initial;">Wyoming</option>
<option value="16865" style="color: initial;">American Samoa</option>
<option value="16860" style="color: initial;">Armed Forces Europe, Middle East, & Canada</option>
<option value="16863" style="color: initial;">Armed Forces Pacific</option>
<option value="16921" style="color: initial;">Canada - Alberta</option>
<option value="16922" style="color: initial;">Canada - British Columbia</option>
<option value="16923" style="color: initial;">Canada - Manitoba</option>
<option value="16924" style="color: initial;">Canada - New Brunswick</option>
<option value="16925" style="color: initial;">Canada - Newfoundland</option>
<option value="16932" style="color: initial;">Canada - Northwest Territories</option>
<option value="16926" style="color: initial;">Canada - Nova Scotia</option>
<option value="16927" style="color: initial;">Canada - Nunavut</option>
<option value="16928" style="color: initial;">Canada - Ontario</option>
<option value="16929" style="color: initial;">Canada - Prince Edward Island</option>
<option value="16930" style="color: initial;">Canada - Quebec</option>
<option value="16931" style="color: initial;">Canada - Saskatchewan</option>
<option value="16933" style="color: initial;">Canada - Yukon Territory</option>
<option value="16870" style="color: initial;">District of Columbia</option>
<option value="16935" style="color: initial;">Federal Jurisdiction</option>
<option value="16873" style="color: initial;">Federated States of Micronesia</option>
<option value="16875" style="color: initial;">Guam</option>
<option value="16887" style="color: initial;">Marshall Islands</option>
<option value="16891" style="color: initial;">Northern Mariana Islands</option>
<option value="16907" style="color: initial;">Palau</option>
<option value="16906" style="color: initial;">Puerto Rico</option>
<option value="16934" style="color: initial;">Unknown or Unspecified</option>
<option value="16915" style="color: initial;">Virgin Islands</option>
</select></span></li>
<li for="CustomText5" label="Zip:"><label for="CustomText5">Zip:</label><span class="value"><input aria-label="Claimant Postal" class="medium textInput" id="CustomText5" maxlength="256" name="CustomText5" type="text" value=""></span>
</li>
<li for="CustomText7" label="Home Phone:"><label for="CustomText7">Home Phone:</label><span class="value"><input aria-label="Claimant Home Phone" class="phoneNumber medium textInput" id="CustomText7"
instructions="Enter digits for 'US' or type + for international numbers." maxlength="256" name="CustomText7" phone-defaultcountry="US" type="text" value=""> <span class="faded">ext</span> <input
aria-label="Claimant Home Phone Extension" class="phoneExtension medium textInput" maxlength="256" name="__phoneExt_CustomText7" type="text" value=""></span><span class="value faded instructions">Enter digits for 'US' or type +
for international numbers.</span></li>
<li for="CustomText31" label="Cell Phone:"><label for="CustomText31">Cell Phone:</label><span class="value"><input aria-label="Claimant Cell Phone" class="phoneNumber medium textInput" id="CustomText31"
instructions="Enter digits for 'US' or type + for international numbers." maxlength="256" name="CustomText31" phone-defaultcountry="US" type="text" value=""> <span class="faded">ext</span> <input
aria-label="Claimant Cell Phone Extension" class="phoneExtension medium textInput" maxlength="256" name="__phoneExt_CustomText31" type="text" value=""></span><span class="value faded instructions">Enter digits for 'US' or type +
for international numbers.</span></li>
<li for="CustomBool5" label="Allow Text?"><label for="CustomBool5">Allow Text?</label><span class="value"><select aria-label="Claimant Allow Text" id="CustomBool5" name="CustomBool5" class="faded">
<option value="" class="faded">- None Selected -</option>
<option value="True" style="color: initial;">Yes</option>
<option value="False" style="color: initial;">No</option>
</select></span></li>
<li for="CustomText32" label="Work Phone:"><label for="CustomText32">Work Phone:</label><span class="value"><input aria-label="Claimant Work Phone" class="phoneNumber medium textInput" id="CustomText32"
instructions="Enter digits for 'US' or type + for international numbers." maxlength="256" name="CustomText32" phone-defaultcountry="US" type="text" value=""> <span class="faded">ext</span> <input
aria-label="Claimant Work Phone Extension" class="phoneExtension medium textInput" maxlength="256" name="__phoneExt_CustomText32" type="text" value=""></span><span class="value faded instructions">Enter digits for 'US' or type +
for international numbers.</span></li>
<li class="required" for="CustomText6" label="E-Mail Address:"><label class="required" for="CustomText6" title="E-Mail Address:. Required field.">E-Mail Address:</label><span class="value"><input aria-label="Claimant Email"
aria-required="true" class="formulaField medium textInput" id="CustomText6" maxlength="256" name="CustomText6" type="text" value=""></span></li>
<li class="hidden" for="Alias_LossEvents_EmployeeEmailVerify" label="Employee Email Verify"><label for="Alias_LossEvents_EmployeeEmailVerify">Employee Email Verify: </label><span class="value"><input
data-origami-formula="({Alias_Event_ClaimantEmail} == '' ? {Alias_Event_ClaimantEmail} : {Alias_Event_ClaimantEmail})" id="CustomText109" name="CustomText109" type="hidden" value="" aria-label="CustomText109"></span></li>
<li class="required" for="CustomText104" label="E-Mail Address Verify:"><label class="required" for="CustomText104" title="E-Mail Address Verify:. Required field.">E-Mail Address Verify:</label><span class="value"><input
aria-label="Claimant Email Verify" aria-required="true" class="medium textInput" id="CustomText104" maxlength="256" name="CustomText104" type="text" value=""></span></li>
</ul>
</div>
</div>
<div class="yui-u doric">
<div class="section">
<ul class="properties wideLabels ">
<li for="CustomText34" label="SSN:"><label for="CustomText34">SSN:</label><span class="value"><input aria-label="Social Security" class="medium socialsecurity medium textInput" id="CustomText34" maxlength="11" name="CustomText34"
type="text" value=""></span></li>
<li for="CustomDate6" label="Date of Birth:"><label for="CustomDate6">Date of Birth:</label><span class="value"><input aria-label="Birth Date" class="formulaField inputDate textInput hasDatepicker" id="CustomDate6" name="CustomDate6"
title="Enter date in MM/dd/yyyy format" type="text" value=""><button type="button" class="ui-datepicker-trigger" aria-label="Click to select date from calendar"
title="Click to select date from calendar"><i class="fal fa-calendar-alt toolTipIconDefaultColor datePickerIconDefault" style="position:relative;top:-2px;"></i></button></span></li>
<li for="CustomNumber4" label="Age:"><label for="CustomNumber4">Age:</label><span class="value"><input alt="decimal.0" aria-label="Claimant Age" class="inputText maskedDecimal textInput"
data-origami-formula="Math.floor((DateUtil.diffInDays({Alias_LossEvent_BirthDate}, new Date())+1)/365.25)" data-originvariantvalue="0" id="CustomNumber4" name="CustomNumber4" readonly="readonly" type="text" value=""
style="text-align: right;"></span></li>
<li for="CustomCode8ID" label="Sex:"><label for="CustomCode8ID">Sex:</label><span class="value"><select aria-label="Gender Loss Event" class="medium faded" data-codetypeid="10242" data-fieldtype="Code" id="CustomCode8ID"
name="CustomCode8ID">
<option value="" class="faded">- None Selected -</option>
<option value="17983" style="color: initial;">Female</option>
<option value="17982" style="color: initial;">Male</option>
<option value="17984" style="color: initial;">Non-Binary</option>
<option value="17985" style="color: initial;">Unspecified</option>
</select></span></li>
<li for="CustomCode9ID" label="Marital Status:"><label for="CustomCode9ID">Marital Status:</label><span class="value"><select aria-label="Marital Status Loss Event" class="medium faded" data-codetypeid="10243" data-fieldtype="Code"
id="CustomCode9ID" name="CustomCode9ID">
<option value="" class="faded">- None Selected -</option>
<option value="17992" style="color: initial;">Common Law</option>
<option value="17986" style="color: initial;">Divorced</option>
<option value="17993" style="color: initial;">Domestic Partnership</option>
<option value="17987" style="color: initial;">Married</option>
<option value="17988" style="color: initial;">Separated</option>
<option value="17989" style="color: initial;">Single</option>
<option value="17991" style="color: initial;">Unknown</option>
<option value="17990" style="color: initial;">Widowed</option>
</select></span></li>
<li for="CustomNumber5" label="Dependents:"><label for="CustomNumber5">Dependents:</label><span class="value"><input alt="decimal.0" aria-label="Number of Dependents" class="inputText maskedDecimal textInput"
data-originvariantvalue="0" id="CustomNumber5" name="CustomNumber5" type="text" value="" style="text-align: right;"></span></li>
<li for="CustomDate7" label="Date of Hire:"><label for="CustomDate7">Date of Hire:</label><span class="value"><input aria-label="Hire Date" class="inputDate textInput hasDatepicker" id="CustomDate7" name="CustomDate7"
title="Enter date in MM/dd/yyyy format" type="text" value=""><button type="button" class="ui-datepicker-trigger" aria-label="Click to select date from calendar"
title="Click to select date from calendar"><i class="fal fa-calendar-alt toolTipIconDefaultColor datePickerIconDefault" style="position:relative;top:-2px;"></i></button></span></li>
<li for="CustomCode10ID" label="State of Hire:"><label for="CustomCode10ID">State of Hire:</label><span class="value"><select aria-label="State of Hire" class="medium faded" data-codetypeid="10002" data-fieldtype="Code"
id="CustomCode10ID" name="CustomCode10ID">
<option value="" class="faded">- None Selected -</option>
<option value="10164" style="color: initial;">Alabama</option>
<option value="10163" style="color: initial;">Alaska</option>
<option value="10166" style="color: initial;">Arizona</option>
<option value="10165" style="color: initial;">Arkansas</option>
<option value="10167" style="color: initial;">California</option>
<option value="10168" style="color: initial;">Colorado</option>
<option value="10169" style="color: initial;">Connecticut</option>
<option value="10171" style="color: initial;">Delaware</option>
<option value="10172" style="color: initial;">Florida</option>
<option value="10173" style="color: initial;">Georgia</option>
<option value="10174" style="color: initial;">Hawaii</option>
<option value="10176" style="color: initial;">Idaho</option>
<option value="10177" style="color: initial;">Illinois</option>
<option value="10178" style="color: initial;">Indiana</option>
<option value="10175" style="color: initial;">Iowa</option>
<option value="10179" style="color: initial;">Kansas</option>
<option value="10180" style="color: initial;">Kentucky</option>
<option value="10181" style="color: initial;">Louisiana</option>
<option value="10184" style="color: initial;">Maine</option>
<option value="10183" style="color: initial;">Maryland</option>
<option value="10182" style="color: initial;">Massachusetts</option>
<option value="10185" style="color: initial;">Michigan</option>
<option value="10186" style="color: initial;">Minnesota</option>
<option value="10188" style="color: initial;">Mississippi</option>
<option value="10187" style="color: initial;">Missouri</option>
<option value="10189" style="color: initial;">Montana</option>
<option value="10192" style="color: initial;">Nebraska</option>
<option value="10196" style="color: initial;">Nevada</option>
<option value="10193" style="color: initial;">New Hampshire</option>
<option value="10194" style="color: initial;">New Jersey</option>
<option value="10195" style="color: initial;">New Mexico</option>
<option value="10197" style="color: initial;">New York</option>
<option value="10190" style="color: initial;">North Carolina</option>
<option value="10191" style="color: initial;">North Dakota</option>
<option value="10198" style="color: initial;">Ohio</option>
<option value="10199" style="color: initial;">Oklahoma</option>
<option value="10200" style="color: initial;">Oregon</option>
<option value="10201" style="color: initial;">Pennsylvania</option>
<option value="10202" style="color: initial;">Rhode Island</option>
<option value="10203" style="color: initial;">South Carolina</option>
<option value="10204" style="color: initial;">South Dakota</option>
<option value="10205" style="color: initial;">Tennessee</option>
<option value="10206" style="color: initial;">Texas</option>
<option value="10207" style="color: initial;">Utah</option>
<option value="10209" style="color: initial;">Vermont</option>
<option value="10208" style="color: initial;">Virginia</option>
<option value="10210" style="color: initial;">Washington</option>
<option value="10212" style="color: initial;">West Virginia</option>
<option value="10211" style="color: initial;">Wisconsin</option>
<option value="10213" style="color: initial;">Wyoming</option>
<option value="14271" style="color: initial;">American Samoa</option>
<option value="14269" style="color: initial;">Armed Forces Europe, Middle East, & Canada</option>
<option value="14270" style="color: initial;">Armed Forces Pacific</option>
<option value="14279" style="color: initial;">Canada - Alberta</option>
<option value="14280" style="color: initial;">Canada - British Columbia</option>
<option value="14281" style="color: initial;">Canada - Manitoba</option>
<option value="14282" style="color: initial;">Canada - New Brunswick</option>
<option value="14290" style="color: initial;">Canada - Northwest Territories</option>
<option value="14283" style="color: initial;">Canada - Newfoundland</option>
<option value="14284" style="color: initial;">Canada - Nova Scotia</option>
<option value="14285" style="color: initial;">Canada - Nunavut</option>
<option value="14286" style="color: initial;">Canada - Ontario</option>
<option value="14287" style="color: initial;">Canada - Prince Edward Island</option>
<option value="14288" style="color: initial;">Canada - Quebec</option>
<option value="14289" style="color: initial;">Canada - Saskatchewan</option>
<option value="14291" style="color: initial;">Canada - Yukon Territory</option>
<option value="10170" style="color: initial;">District of Columbia</option>
<option value="14292" style="color: initial;">Federal Jurisdiction</option>
<option value="14272" style="color: initial;">Federated States of Micronesia</option>
<option value="14273" style="color: initial;">Guam</option>
<option value="14274" style="color: initial;">Marshall Islands</option>
<option value="14275" style="color: initial;">Northern Mariana Islands</option>
<option value="14277" style="color: initial;">Palau</option>
<option value="14276" style="color: initial;">Puerto Rico</option>
<option value="10214" style="color: initial;">Unknown or Unspecified</option>
<option value="14278" style="color: initial;">Virgin Islands</option>
</select></span></li>
<li for="CustomText35" label="Occupation:"><label for="CustomText35">Occupation:</label><span class="value"><input aria-label="Occupation" class="medium textInput" id="CustomText35" maxlength="256" name="CustomText35" type="text"
value=""></span></li>
<li for="CustomCode11ID" label="Employment Status:"><label for="CustomCode11ID">Employment Status:</label><span class="value"><select aria-label="Employment Status" class="medium faded" data-codetypeid="10244" data-fieldtype="Code"
id="CustomCode11ID" name="CustomCode11ID">
<option value="" class="faded">- None Selected -</option>
<option value="17997" style="color: initial;">Apprenticeship Full-time</option>
<option value="17998" style="color: initial;">Apprenticeship Part-time</option>
<option value="18005" style="color: initial;">Disabled</option>
<option value="18001" style="color: initial;">Non-Benefited Employee</option>
<option value="18004" style="color: initial;">On Strike</option>
<option value="18006" style="color: initial;">Other</option>
<option value="18000" style="color: initial;">Part-time Employee</option>
<option value="17994" style="color: initial;">Piece Worker</option>
<option value="17999" style="color: initial;">Regular/Full-time Employee</option>
<option value="18003" style="color: initial;">Retired</option>
<option value="17996" style="color: initial;">Seasonal Worker</option>
<option value="18002" style="color: initial;">Unemployed/Not Employed</option>
<option value="17995" style="color: initial;">Volunteer</option>
</select></span></li>
<li for="CustomMoney1" label="Rate of Pay:"><label for="CustomMoney1">Rate of Pay:</label><span class="value"><input alt="decimal.2" aria-label="Wage Rate" class="inputText maskedDecimal textInput" data-originvariantvalue="0"
id="CustomMoney1" name="CustomMoney1" type="text" value="" style="text-align: right;"></span></li>
<li for="CustomCode12ID" label="Per:"><label for="CustomCode12ID">Per:</label><span class="value"><select aria-label="Wage Rate Type" class="medium faded" data-codetypeid="10245" data-fieldtype="Code" id="CustomCode12ID"
name="CustomCode12ID">
<option value="" class="faded">- None Selected -</option>
<option value="18013" style="color: initial;">Annually</option>
<option value="18010" style="color: initial;">BiWeekly</option>
<option value="18008" style="color: initial;">Daily</option>
<option value="18007" style="color: initial;">Hourly</option>
<option value="18011" style="color: initial;">Monthly</option>
<option value="18012" style="color: initial;">Semi-Monthly</option>
<option value="18009" style="color: initial;">Weekly</option>
</select></span></li>
<li for="CustomMultiSelectCode1" label="Days Worked Per Week:"><label for="CustomMultiSelectCode1">Days Worked Per Week:</label><span class="value">
<div class="multiselectcheckboxlist" id="CustomMultiSelectCode1">
<label style="clear:none;width:auto;float:none"><input aria-label="Sun" name="__multiselect_CustomMultiSelectCode1" type="checkbox" value="18839"><span style="margin-left:5px;margin-right:10px">Sun</span></label><br><label
style="clear:none;width:auto;float:none"><input aria-label="Mon" name="__multiselect_CustomMultiSelectCode1" type="checkbox" value="18840"><span style="margin-left:5px;margin-right:10px">Mon</span></label><br><label
style="clear:none;width:auto;float:none"><input aria-label="Tue" name="__multiselect_CustomMultiSelectCode1" type="checkbox" value="18841"><span style="margin-left:5px;margin-right:10px">Tue</span></label><br><label
style="clear:none;width:auto;float:none"><input aria-label="Wed" name="__multiselect_CustomMultiSelectCode1" type="checkbox" value="18842"><span style="margin-left:5px;margin-right:10px">Wed</span></label><br><label
style="clear:none;width:auto;float:none"><input aria-label="Thu" name="__multiselect_CustomMultiSelectCode1" type="checkbox" value="18843"><span style="margin-left:5px;margin-right:10px">Thu</span></label><br><label
style="clear:none;width:auto;float:none"><input aria-label="Fri" name="__multiselect_CustomMultiSelectCode1" type="checkbox" value="18844"><span style="margin-left:5px;margin-right:10px">Fri</span></label><br><label
style="clear:none;width:auto;float:none"><input aria-label="Sat" name="__multiselect_CustomMultiSelectCode1" type="checkbox" value="18845"><span style="margin-left:5px;margin-right:10px">Sat</span></label><br>
</div><input aria-label="Days Worked Per Week:" name="__multiselect_CustomMultiSelectCode1" type="hidden" value="">
</span></li>
<li for="CustomBool6" label="Paid in full for date of injury:"><label for="CustomBool6">Paid in full for date of injury:</label><span class="value"><select aria-label="Full Pay on Day of Injury" id="CustomBool6" name="CustomBool6"
class="faded">
<option value="" class="faded">- None Selected -</option>
<option value="True" style="color: initial;">Yes</option>
<option value="False" style="color: initial;">No</option>
</select></span></li>
<li for="CustomBool7" label="Did Salary Continue:"><label for="CustomBool7">Did Salary Continue:</label><span class="value"><select aria-label="Salary Continued Indicator" id="CustomBool7" name="CustomBool7" class="faded">
<option value="" class="faded">- None Selected -</option>
<option value="True" style="color: initial;">Yes</option>
<option value="False" style="color: initial;">No</option>
</select></span></li>
</ul>
</div>
</div>
</div>
<div aria-labelledby="title_Injury/OccurrenceInformation" class="panel yui-g" role="region">
<h3 id="title_Injury/OccurrenceInformation" tabindex="-1">Injury/Occurrence Information</h3>
<div class="yui-u first">
<div class="section">
<ul class="properties wideLabels ">
<li for="CustomBool8" label="Is there an injured party related to this claim?"><label for="CustomBool8">Is there an injured party related to this claim?</label><span class="value"><select
aria-label="Is There An Injured Party Related to Claim" id="CustomBool8" name="CustomBool8">
<option value="" class="faded">- None Selected -</option>
<option selected="selected" value="True" style="color: initial;">Yes</option>
<option value="False" style="color: initial;">No</option>
</select></span></li>
<li for="CustomBool9" label="Is there an attorney representative related to this claim?"><label for="CustomBool9">Is there an attorney representative related to this claim?</label><span class="value"><select
aria-label="Claimant Represented" id="CustomBool9" name="CustomBool9" class="faded">
<option value="" class="faded">- None Selected -</option>
<option value="True" style="color: initial;">Yes</option>
<option value="False" style="color: initial;">No</option>
</select></span></li>
<li class="required" for="StartDate" label="Date of Injury:"><label class="required" for="StartDate" title="Date of Injury:. Required field.">Date of Injury:</label><span class="value"><input aria-label="Start Date"
aria-required="true" class="inputDate textInput hasDatepicker" id="StartDate" name="StartDate" title="Enter date in MM/dd/yyyy format" type="text" value=""><button type="button" class="ui-datepicker-trigger"
aria-label="Click to select date from calendar" title="Click to select date from calendar"><i class="fal fa-calendar-alt toolTipIconDefaultColor datePickerIconDefault" style="position:relative;top:-2px;"></i></button></span>
</li>
<li for="CustomNumber6" label="Time of Injury:"><label for="CustomNumber6">Time of Injury:</label><span class="value"><input aria-label="Loss Time" class="inputTime textInput is-timeEntry" id="CustomNumber6" name="CustomNumber6"
type="text" value=""></span></li>
<li class="required" for="ReportDate" label="Report Date:"><label class="required" for="ReportDate" title="Report Date:. Required field.">Report Date:</label><span class="value"><input aria-label="Report Date" aria-required="true"
class="inputDate textInput hasDatepicker" id="ReportDate" name="ReportDate" title="Enter date in MM/dd/yyyy format" type="text" value=""><button type="button" class="ui-datepicker-trigger"
aria-label="Click to select date from calendar" title="Click to select date from calendar"><i class="fal fa-calendar-alt toolTipIconDefaultColor datePickerIconDefault" style="position:relative;top:-2px;"></i></button></span>
</li>
<li for="CustomNumber7" label="Time Employee Began Work:"><label for="CustomNumber7">Time Employee Began Work:</label><span class="value"><input aria-label="Time Began Work" class="inputTime textInput is-timeEntry" id="CustomNumber7"
name="CustomNumber7" type="text" value=""></span></li>
<li for="CustomDate8" label="Date Employer Notified:"><label for="CustomDate8">Date Employer Notified:</label><span class="value"><input aria-label="Date Known By Employer" class="inputDate textInput hasDatepicker" id="CustomDate8"
name="CustomDate8" title="Enter date in MM/dd/yyyy format" type="text" value=""><button type="button" class="ui-datepicker-trigger" aria-label="Click to select date from calendar"
title="Click to select date from calendar"><i class="fal fa-calendar-alt toolTipIconDefaultColor datePickerIconDefault" style="position:relative;top:-2px;"></i></button></span></li>
<li for="CustomDate9" label="Last Worked Date:"><label for="CustomDate9">Last Worked Date:</label><span class="value"><input aria-label="Last Worked Date" class="inputDate textInput hasDatepicker" id="CustomDate9" name="CustomDate9"
title="Enter date in MM/dd/yyyy format" type="text" value=""><button type="button" class="ui-datepicker-trigger" aria-label="Click to select date from calendar"
title="Click to select date from calendar"><i class="fal fa-calendar-alt toolTipIconDefaultColor datePickerIconDefault" style="position:relative;top:-2px;"></i></button></span></li>
<li for="CustomDate10" label="Date Disability Began:"><label for="CustomDate10">Date Disability Began:</label><span class="value"><input aria-label="Disability Date" class="inputDate textInput hasDatepicker" id="CustomDate10"
name="CustomDate10" title="Enter date in MM/dd/yyyy format" type="text" value=""><button type="button" class="ui-datepicker-trigger" aria-label="Click to select date from calendar"
title="Click to select date from calendar"><i class="fal fa-calendar-alt toolTipIconDefaultColor datePickerIconDefault" style="position:relative;top:-2px;"></i></button></span></li>
<li for="CustomDate11" label="Date Returned to Work:"><label for="CustomDate11">Date Returned to Work:</label><span class="value"><input aria-label="Date Returned to Work" class="inputDate textInput hasDatepicker" id="CustomDate11"
name="CustomDate11" title="Enter date in MM/dd/yyyy format" type="text" value=""><button type="button" class="ui-datepicker-trigger" aria-label="Click to select date from calendar"
title="Click to select date from calendar"><i class="fal fa-calendar-alt toolTipIconDefaultColor datePickerIconDefault" style="position:relative;top:-2px;"></i></button></span></li>
<li for="CustomBool10" label="Is Light Duty Work Available"><label for="CustomBool10">Is Light Duty Work Available: </label><span class="value"><select aria-label="Is Light Duty Work Available" id="CustomBool10"
name="CustomBool10" class="faded">
<option value="" class="faded">- None Selected -</option>
<option value="True" style="color: initial;">Yes</option>
<option value="False" style="color: initial;">No</option>
</select></span></li>
<li for="CustomBool11" label="Were safety measures followed?"><label for="CustomBool11">Were safety measures followed?</label><span class="value"><select aria-label="Were Safety Measures Followed" id="CustomBool11" name="CustomBool11"
class="faded">
<option value="" class="faded">- None Selected -</option>
<option value="True" style="color: initial;">Yes</option>
<option value="False" style="color: initial;">No</option>
</select></span></li>
<li for="CustomCode13ID" label="Death Result of Injury"><label for="CustomCode13ID">Death Result of Injury: </label><span class="value"><select aria-label="Death Result of Injury" class="medium faded" data-codetypeid="10060"
data-fieldtype="Code" id="CustomCode13ID" name="CustomCode13ID">
<option value="" class="faded">- None Selected -</option>
<option value="15004" style="color: initial;">No</option>
<option value="15005" style="color: initial;">Unknown</option>
<option value="15003" style="color: initial;">Yes</option>
</select></span></li>
<li for="CustomDate12" label="Date of Death:"><label for="CustomDate12">Date of Death:</label><span class="value"><input aria-label="Death Date" class="inputDate textInput hasDatepicker" id="CustomDate12" name="CustomDate12"
title="Enter date in MM/dd/yyyy format" type="text" value=""><button type="button" class="ui-datepicker-trigger" aria-label="Click to select date from calendar"
title="Click to select date from calendar"><i class="fal fa-calendar-alt toolTipIconDefaultColor datePickerIconDefault" style="position:relative;top:-2px;"></i></button></span></li>
<li for="CustomCode15ID" label="Cause of Injury:"><label for="CustomCode15ID">Cause of Injury:</label><span class="value"><select aria-label="Cause Loss Event" class="medium faded" data-codetypeid="10247" data-fieldtype="Code"
id="CustomCode15ID" name="CustomCode15ID">
<option value="" class="faded">- None Selected -</option>
<option value="18017" style="color: initial;">Burn - Chemical</option>
<option value="18027" style="color: initial;">Burn - Cold Objects or Substances</option>
<option value="18025" style="color: initial;">Burn - Contact NOC</option>
<option value="18020" style="color: initial;">Burn - Fire or Flame</option>
<option value="18018" style="color: initial;">Burn - Hot Objects or Substances</option>
<option value="18021" style="color: initial;">Burn - Steam or Hot Fluids</option>
<option value="18019" style="color: initial;">Burn - Temperature Extremes</option>
<option value="18023" style="color: initial;">Burn - Welding Operation</option>
<option value="18026" style="color: initial;">Caught In, Under, or Between - Machine or Machinery</option>
<option value="18028" style="color: initial;">Caught In, Under, or Between - Object Handled</option>
<option value="18036" style="color: initial;">Caught In, Under, or Between Collapsing Materials</option>
<option value="18029" style="color: initial;">Caught In, Under, or Between NOC</option>
<option value="18091" style="color: initial;">Cumulative, NOC</option>
<option value="18031" style="color: initial;">Cut, Puncture, or Scrape - Broken Glass</option>
<option value="18032" style="color: initial;">Cut, Puncture, or Scrape - Hand Tool</option>
<option value="18033" style="color: initial;">Cut, Puncture, or Scrape - Object Being Handled</option>
<option value="18034" style="color: initial;">Cut, Puncture, or Scrape - Powered Hand Tool</option>
<option value="18035" style="color: initial;">Cut, Puncture, or Scrape NOC</option>
<option value="18078" style="color: initial;">Electrical Contact</option>
<option value="18030" style="color: initial;">Exposure - Abnormal Air Pressure</option>
<option value="18037" style="color: initial;">Fall, Slip, or Trip - Different Level</option>
<option value="18044" style="color: initial;">Fall, Slip, or Trip - Ice or Snow</option>
<option value="18040" style="color: initial;">Fall, Slip, or Trip - Into Openings</option>
<option value="18038" style="color: initial;">Fall, Slip, or Trip - Ladder or Scaffolding</option>
<option value="18039" style="color: initial;">Fall, Slip, or Trip - Liquid or Grease</option>
<option value="18041" style="color: initial;">Fall, Slip, or Trip - On Same Level</option>
<option value="18045" style="color: initial;">Fall, Slip, or Trip - On Stairs</option>
<option value="18043" style="color: initial;">Fall, Slip, or Trip NOC</option>
<option value="18081" style="color: initial;">Foreign Matter in Eye(s)</option>
<option value="18086" style="color: initial;">Gunshot</option>
<option value="18022" style="color: initial;">Inhalation of Dust, Gases, Fumes or Vapors</option>
<option value="18085" style="color: initial;">Mold or Mildew</option>
<option value="18048" style="color: initial;">Motor Vehicle - Collision or Sideswipe with Another Vehicle</option>
<option value="18049" style="color: initial;">Motor Vehicle - Collision with a Fixed Object</option>
<option value="18050" style="color: initial;">Motor Vehicle - Crash of Airplane</option>
<option value="18047" style="color: initial;">Motor Vehicle - Crash of Rail Vehicle</option>
<option value="18046" style="color: initial;">Motor Vehicle - Crash of Water Vehicle</option>
<option value="18051" style="color: initial;">Motor Vehicle - Vehicle Upset</option>
<option value="18052" style="color: initial;">Motor Vehicle NOC</option>
<option value="18082" style="color: initial;">Natural Disasters</option>
<option value="18077" style="color: initial;">Not otherwise classified in any other code. Applies only to non-impact cases in which the injury resulted from inhalation, absorption (skin contact), ingestion of harmful substances,
or vaccinations</option>
<option value="18084" style="color: initial;">Other than Physical Cause of Injury</option>
<option value="18092" style="color: initial;">Other, Miscellaneous NOC</option>
<option value="18352" style="color: initial;">Pandemic</option>
<option value="18083" style="color: initial;">Person in Act of Crime</option>
<option value="18024" style="color: initial;">Radiation</option>
<option value="18087" style="color: initial;">Rubbed or Abraded By - Repetitive Motion</option>
<option value="18088" style="color: initial;">Rubbed or Abraded By NOC</option>
<option value="18042" style="color: initial;">Slip or Trip, Did Not Fall</option>
<option value="18067" style="color: initial;">Stepping on Sharp Object</option>
<option value="18053" style="color: initial;">Strain or Injury By - Continual Noise</option>
<option value="18056" style="color: initial;">Strain or Injury By - Holding or Carrying</option>
<option value="18055" style="color: initial;">Strain or Injury By - Jumping or Leaping</option>
<option value="18057" style="color: initial;">Strain or Injury By - Lifting</option>
<option value="18058" style="color: initial;">Strain or Injury By - Pushing or Pulling</option>
<option value="18059" style="color: initial;">Strain or Injury By - Reaching</option>
<option value="18090" style="color: initial;">Strain or Injury By - Repetitive Motion</option>
<option value="18054" style="color: initial;">Strain or Injury By - Twisting</option>
<option value="18060" style="color: initial;">Strain or Injury By - Using Tool or Machinery</option>
<option value="18062" style="color: initial;">Strain or Injury By - Welding or Throwing</option>
<option value="18061" style="color: initial;">Strain Or Injury By NOC</option>
<option value="18063" style="color: initial;">Striking Against or Stepping On - Moving Part of Machine</option>
<option value="18064" style="color: initial;">Striking Against or Stepping On - Object Being Lifted or Handled</option>
<option value="18065" style="color: initial;">Striking Against or Stepping On - Sanding, Scraping, Cleaning Operation</option>
<option value="18066" style="color: initial;">Striking Against or Stepping On - Stationary Object</option>
<option value="18068" style="color: initial;">Striking Against or Stepping On NOC</option>
<option value="18079" style="color: initial;">Struck or Injured By - Animal or Insect</option>
<option value="18080" style="color: initial;">Struck or Injured By - Explosion or Flare Back</option>
<option value="18070" style="color: initial;">Struck or Injured By - Falling or Flying Object</option>
<option value="18069" style="color: initial;">Struck or Injured By - Fellow Worker, Patient, or Other Person</option>
<option value="18071" style="color: initial;">Struck or Injured By - Hand Tool in Use</option>
<option value="18072" style="color: initial;">Struck or Injured By - Motor Vehicle</option>
<option value="18073" style="color: initial;">Struck or Injured By - Moving Parts of Machine</option>
<option value="18075" style="color: initial;">Struck or Injured By - Object Being Handled by Others</option>
<option value="18074" style="color: initial;">Struck or Injured By - Object Being Lifted or Handled</option>
<option value="18076" style="color: initial;">Struck or Injured By NOC</option>
<option value="18089" style="color: initial;">Terrorism</option>
</select></span></li>
<li for="CustomCode16ID" label="Nature of Injury:"><label for="CustomCode16ID">Nature of Injury:</label><span class="value"><select aria-label="Nature Loss Event" class="medium faded" data-codetypeid="10248" data-fieldtype="Code"
id="CustomCode16ID" name="CustomCode16ID">
<option value="" class="faded">- None Selected -</option>
<option value="18429" style="color: initial;">Adverse reaction to a vaccination or inoculation</option>
<option value="18420" style="color: initial;">AIDS</option>
<option value="18425" style="color: initial;">All Other Cumulative Injury, NOC</option>
<option value="18416" style="color: initial;">All Other Occupational Disease Injury, NOC</option>
<option value="18404" style="color: initial;">All Other Specific Injuries, NOC</option>
<option value="18375" style="color: initial;">Amputation</option>
<option value="18376" style="color: initial;">Angina Pectoris</option>
<option value="18406" style="color: initial;">Asbestosis</option>
<option value="18401" style="color: initial;">Asphyxiation</option>
<option value="18407" style="color: initial;">Black Lung</option>
<option value="18377" style="color: initial;">Burn</option>
<option value="18408" style="color: initial;">Byssinosis</option>
<option value="18419" style="color: initial;">Cancer</option>
<option value="18423" style="color: initial;">Carpal Tunnel Syndrome</option>
<option value="18378" style="color: initial;">Concussion</option>
<option value="18418" style="color: initial;">Contagious Disease</option>
<option value="18379" style="color: initial;">Contusion</option>
<option value="18428" style="color: initial;">COVID-19</option>
<option value="18380" style="color: initial;">Crushing</option>
<option value="18413" style="color: initial;">Dermatitis</option>
<option value="18381" style="color: initial;">Dislocation</option>
<option value="18405" style="color: initial;">Dust Disease, NOC</option>
<option value="18382" style="color: initial;">Electric Shock</option>
<option value="18383" style="color: initial;">Enucleation</option>
<option value="18384" style="color: initial;">Foreign Body</option>
<option value="18385" style="color: initial;">Fracture</option>
<option value="18386" style="color: initial;">Freezing</option>
<option value="18387" style="color: initial;">Hearing Loss or Impairment</option>
<option value="18388" style="color: initial;">Heat Prostration</option>
<option value="18424" style="color: initial;">Hepatitis C</option>
<option value="18389" style="color: initial;">Hernia</option>
<option value="18390" style="color: initial;">Infection</option>
<option value="18391" style="color: initial;">Inflammation</option>
<option value="18392" style="color: initial;">Laceration</option>
<option value="18417" style="color: initial;">Loss of Hearing</option>
<option value="18414" style="color: initial;">Mental Disorder</option>
<option value="18422" style="color: initial;">Mental Stress</option>
<option value="18427" style="color: initial;">Multiple Injuries Including Both Physical and Psychological</option>
<option value="18426" style="color: initial;">Multiple Physical Injuries Only</option>
<option value="18393" style="color: initial;">Myocardial Infarction</option>
<option value="18374" style="color: initial;">No Physical Injury</option>
<option value="18411" style="color: initial;">Poisoning - Chemical (other than metals)</option>
<option value="18394" style="color: initial;">Poisoning - General (Not OD or Cumulative Injury)</option>
<option value="18412" style="color: initial;">Poisoning - Metals</option>
<option value="18395" style="color: initial;">Puncture</option>
<option value="18415" style="color: initial;">Radiation</option>
<option value="18410" style="color: initial;">Respiratory Disorders</option>
<option value="18396" style="color: initial;">Rupture</option>
<option value="18397" style="color: initial;">Severance</option>
<option value="18409" style="color: initial;">Silicosis</option>
<option value="18398" style="color: initial;">Sprain or Tear</option>
<option value="18399" style="color: initial;">Strain or Tear</option>
<option value="18400" style="color: initial;">Syncope</option>
<option value="18402" style="color: initial;">Vascular</option>
<option value="18421" style="color: initial;">VDT - Related Diseases</option>
<option value="18403" style="color: initial;">Vision Loss</option>
</select></span></li>
<li for="CustomCode17ID" label="Body Part(s)"><label for="CustomCode17ID">Body Part(s)</label><span class="value"><select aria-label="Body Part Loss Event" class="medium faded" data-codetypeid="10249" data-fieldtype="Code"
id="CustomCode17ID" name="CustomCode17ID">
<option value="" class="faded">- None Selected -</option>
<option value="18512" style="color: initial;">Abdomen Including Groin</option>
<option value="18497" style="color: initial;">Ankle</option>
<option value="18515" style="color: initial;">Artificial Appliance</option>
<option value="18440" style="color: initial;">Blindness in both eyes</option>
<option value="18519" style="color: initial;">Body Systems and Multiple Body Systems</option>
<option value="18432" style="color: initial;">Brain</option>
<option value="18513" style="color: initial;">Buttocks</option>
<option value="18486" style="color: initial;">Chest - includes ribs, sternum, soft tissue</option>
<option value="18485" style="color: initial;">Disc-Back</option>
<option value="18448" style="color: initial;">Disc-Neck</option>
<option value="18433" style="color: initial;">Ear(s)</option>
<option value="18455" style="color: initial;">Elbow</option>
<option value="18437" style="color: initial;">Eye(s)</option>
<option value="18445" style="color: initial;">Facial Bones-includes jaw</option>
<option value="18459" style="color: initial;">Finger(s)</option>
<option value="18498" style="color: initial;">Foot</option>
<option value="18507" style="color: initial;">Great Toe</option>
<option value="18458" style="color: initial;">Hand</option>
<option value="18444" style="color: initial;">Head - Soft Tissue - includes face, cheek, forehead, scalp</option>
<option value="18491" style="color: initial;">Heart</option>
<option value="18493" style="color: initial;">Hip</option>
<option value="18516" style="color: initial;">Insufficient Info to Properly Identify - Unclassified</option>
<option value="18490" style="color: initial;">Internal Organs</option>
<option value="18495" style="color: initial;">Knee</option>
<option value="18450" style="color: initial;">Larynx</option>
<option value="18501" style="color: initial;">Little toe at distal joint</option>
<option value="18500" style="color: initial;">Little toe metatarsal bone</option>
<option value="18508" style="color: initial;">Loss of great toe and metacarpal bone thereof</option>
<option value="18509" style="color: initial;">Loss of great toe at proximal joint</option>
<option value="18510" style="color: initial;">Loss of great toe at second or distal joint</option>
<option value="18460" style="color: initial;">Loss of index finger and metacarpal bone thereof</option>
<option value="18463" style="color: initial;">Loss of index finger at distal joint</option>
<option value="18461" style="color: initial;">Loss of index finger at proximal joint</option>
<option value="18462" style="color: initial;">Loss of index finger at second joint</option>
<option value="18472" style="color: initial;">Loss of little finger and metacarpal bone thereof</option>
<option value="18475" style="color: initial;">Loss of little finger at distal joint</option>
<option value="18473" style="color: initial;">Loss of little finger at proximal joint</option>
<option value="18474" style="color: initial;">Loss of little finger at second joint</option>
<option value="18464" style="color: initial;">Loss of middle finger and metacarpal bone thereof</option>
<option value="18467" style="color: initial;">Loss of middle finger at distal joint</option>
<option value="18465" style="color: initial;">Loss of middle finger at proximal joint</option>
<option value="18466" style="color: initial;">Loss of middle finger at second joint</option>
<option value="18468" style="color: initial;">Loss of ring finger and metacarpal bone thereof</option>
<option value="18471" style="color: initial;">Loss of ring finger at distal joint</option>
<option value="18469" style="color: initial;">Loss of ring finger at proximal joint</option>
<option value="18470" style="color: initial;">Loss of ring finger at second joint</option>
<option value="18477" style="color: initial;">Loss of thumb and metacarpal bone thereof</option>
<option value="18478" style="color: initial;">Loss of thumb at proximal joint</option>
<option value="18479" style="color: initial;">Loss of thumb at second or distal joint</option>
<option value="18456" style="color: initial;">Lower Arm</option>
<option value="18484" style="color: initial;">Lower Back Area</option>
<option value="18496" style="color: initial;">Lower Leg</option>
<option value="18514" style="color: initial;">Lumbar & or Sacral Vertebrae</option>
<option value="18511" style="color: initial;">Lungs</option>
<option value="18443" style="color: initial;">Mouth-includes lips, tongue</option>
<option value="18518" style="color: initial;">Multiple Body Parts (Including Body Systems and Body Parts)</option>
<option value="18430" style="color: initial;">Multiple Head Injury</option>
<option value="18492" style="color: initial;">Multiple Lower Extremities</option>
<option value="18446" style="color: initial;">Multiple Neck Injury</option>
<option value="18482" style="color: initial;">Multiple Trunk</option>
<option value="18453" style="color: initial;">Multiple Upper Extremities</option>
<option value="18451" style="color: initial;">Neck - Soft Tissue</option>
<option value="18449" style="color: initial;">Neck - Spinal Cord</option>
<option value="18517" style="color: initial;">No Physical Injury</option>
<option value="18441" style="color: initial;">Nose</option>
<option value="18488" style="color: initial;">Pelvis</option>
<option value="18487" style="color: initial;">Sacrum and Coccyx</option>
<option value="18480" style="color: initial;">Shoulder(s)</option>
<option value="18431" style="color: initial;">Skull</option>
<option value="18442" style="color: initial;">Teeth</option>
<option value="18506" style="color: initial;">The loss of any other toe at the distal joint</option>
<option value="18504" style="color: initial;">The loss of any other toe at the middle joint</option>
<option value="18503" style="color: initial;">The loss of any other toe at the proximal joint</option>
<option value="18505" style="color: initial;">The loss of any other toe at the second joint</option>
<option value="18502" style="color: initial;">The loss of any other toe with the metatarsal bone thereof</option>
<option value="18438" style="color: initial;">The loss of eye by enucleation (including disfigurement resulting there from)</option>
<option value="18476" style="color: initial;">Thumb</option>
<option value="18499" style="color: initial;">Toes</option>
<option value="18439" style="color: initial;">Total blindness of one eye</option>
<option value="18434" style="color: initial;">Total Deafness of Both Ears</option>
<option value="18435" style="color: initial;">Total Deafness of One Ear</option>
<option value="18436" style="color: initial;">Total deafness of one ear after other ear deaf prior to injury</option>
<option value="18452" style="color: initial;">Trachea</option>
<option value="18489" style="color: initial;">Trunk - Spinal Cord</option>
<option value="18454" style="color: initial;">Upper Arm</option>
<option value="18483" style="color: initial;">Upper Back Area</option>
<option value="18494" style="color: initial;">Upper Leg</option>
<option value="18447" style="color: initial;">Vertebrae-Neck</option>
<option value="18520" style="color: initial;">Whole Body</option>
<option value="18457" style="color: initial;">Wrist</option>
<option value="18481" style="color: initial;">Wrist(s) and Hand(s)</option>
</select></span></li>
<li class="required" for="CustomCode18ID" label="Injury Type or Location"><label class="required" for="CustomCode18ID" title="Injury Type or Location. Required field.">Injury Type or Location: </label><span class="value"><select
aria-label="Injury Type or Location" aria-required="true" class="medium faded" data-codetypeid="10206" data-fieldtype="Code" id="CustomCode18ID" name="CustomCode18ID">
<option value="" class="faded">- None Selected -</option>
<option value="28905" style="color: initial;">Minor - No Injuries, Report Only</option>
<option value="28906" style="color: initial;">Minor - Laceration, Puncture, Abrasion</option>
<option value="28907" style="color: initial;">Minor - Needle Stick, Bite Wound, Eye Injury</option>
<option value="28908" style="color: initial;">Minor - Irritations, Rashes, 1st Degree Burns</option>
<option value="28909" style="color: initial;">Minor - Strain, Sprain, Contusion</option>
<option value="28910" style="color: initial;">Minor - Unspecified Injury, All Other</option>
<option value="28911" style="color: initial;">Moderate - Fracture, Dislocation, Tear</option>
<option value="28912" style="color: initial;">Moderate - Repetitive Motion, Carpal Tunnel</option>
<option value="28913" style="color: initial;">Moderate - Hernia, Groin, or Abdominal Injury</option>
<option value="28914" style="color: initial;">Moderate - Covid-19, Respiratory, Syncope</option>
<option value="28923" style="color: initial;">Moderate - 2nd Degree Burns</option>
<option value="28915" style="color: initial;">Moderate - Multiple Injuries, All Other</option>
<option value="28916" style="color: initial;">Severe - Concussion, Closed Head Injury</option>
<option value="28917" style="color: initial;">Severe - Traumatic Brain Injury</option>
<option value="28918" style="color: initial;">Severe - Spinal Injury, Disc Herniation</option>
<option value="28919" style="color: initial;">Severe - Amputation</option>
<option value="28920" style="color: initial;">Severe - Catastrophic, or Fatal Injuries</option>
<option value="28921" style="color: initial;">Severe - 3rd Degree Burns</option>
<option value="28922" style="color: initial;">Severe - Trauma or ICU, All Other</option>
</select></span></li>
</ul>
</div>
</div>
<div class="yui-u doric">
<div class="section">
<ul class="properties wideLabels ">
<li for="CustomBool12" label="Police/Fire Contacted?"><label for="CustomBool12">Police/Fire Contacted?</label><span class="value"><select aria-label="Police Contacted" id="CustomBool12" name="CustomBool12" class="faded">
<option value="" class="faded">- None Selected -</option>
<option value="True" style="color: initial;">Yes</option>
<option value="False" style="color: initial;">No</option>
</select></span></li>
<li for="CustomNarrative4" label="Activity During Accident"><label for="CustomNarrative4">Activity During Accident: </label><span class="value"><textarea aria-label="Activity During Accident" class="medium" cols="20"
id="CustomNarrative4" maxlength="" name="CustomNarrative4" rows="2"></textarea></span></li>
<li class="required" for="EventDescription" label="Event Description:"><label class="required" for="EventDescription" title="Event Description:. Required field.">Event Description:</label><span class="value"><textarea
aria-label="Claim Description" aria-required="true" class="medium" cols="20" id="EventDescription" maxlength="" name="EventDescription" rows="2"></textarea></span></li>
<li class="required" for="CustomNarrative2" label="Loss Description"><label class="required" for="CustomNarrative2" title="Loss Description. Required field.">Loss Description: </label><span class="value"><textarea
aria-label="Loss Description" aria-required="true" class="medium" cols="20" id="CustomNarrative2" maxlength="" name="CustomNarrative2" rows="2"></textarea></span></li>
<li for="CustomBool25" label="Did injury, illness, or exposure occur on employer’s premises?"><label for="CustomBool25">Did injury, illness, or exposure occur on employer’s premises?</label><span class="value"><select
aria-label="Injury On Premises" id="CustomBool25" name="CustomBool25" class="faded">
<option value="" class="faded">- None Selected -</option>
<option value="True" style="color: initial;">Yes</option>
<option value="False" style="color: initial;">No</option>
</select></span></li>
<li for="CustomText37" label="Accident Site Organization Name"><label for="CustomText37">Accident Site Organization Name: </label><span class="value"><input aria-label="Accident Site Organization Name" class="medium textInput"
id="CustomText37" maxlength="256" name="CustomText37" type="text" value=""></span></li>
<li for="CustomNarrative1" label="Location Accident Occurred:"><label for="CustomNarrative1">Location Accident Occurred:</label><span class="value"><textarea aria-label="Accident Location Information" class="medium" cols="20"
id="CustomNarrative1" maxlength="" name="CustomNarrative1" rows="2"></textarea></span></li>
<li for="Street1" label="Accident Street1"><label for="Street1">Accident Street1: </label><span class="value"><input aria-label="Street1" class="medium textInput" id="Street1" maxlength="250" name="Street1" type="text"
value=""></span></li>
<li for="Street2" label="Accident Street2"><label for="Street2">Accident Street2: </label><span class="value"><input aria-label="Street2" class="medium textInput" id="Street2" maxlength="250" name="Street2" type="text"
value=""></span></li>
<li for="City" label="Accident City"><label for="City">Accident City: </label><span class="value"><input aria-label="City" class="medium textInput" id="City" maxlength="50" name="City" type="text" value=""></span></li>
<li for="County" label="Accident County"><label for="County">Accident County: </label><span class="value"><input aria-label="County" class="medium textInput" id="County" maxlength="50" name="County" type="text" value=""></span>
</li>
<li for="StateID" label="Accident State"><label for="StateID">Accident State: </label><span class="value"><select aria-label="State" class="medium faded" data-fieldtype="State" id="StateID" name="StateID">
<option value="" class="faded">- None Selected -</option>
<option value="3" style="color: initial;">Alabama</option>
<option value="2" style="color: initial;">Alaska</option>
<option value="7" style="color: initial;">Arizona</option>
<option value="5" style="color: initial;">Arkansas</option>
<option value="8" style="color: initial;">California</option>
<option value="9" style="color: initial;">Colorado</option>
<option value="10" style="color: initial;">Connecticut</option>
<option value="12" style="color: initial;">Delaware</option>
<option value="13" style="color: initial;">Florida</option>
<option value="15" style="color: initial;">Georgia</option>
<option value="17" style="color: initial;">Hawaii</option>
<option value="19" style="color: initial;">Idaho</option>
<option value="20" style="color: initial;">Illinois</option>
<option value="21" style="color: initial;">Indiana</option>
<option value="18" style="color: initial;">Iowa</option>
<option value="22" style="color: initial;">Kansas</option>
<option value="23" style="color: initial;">Kentucky</option>
<option value="24" style="color: initial;">Louisiana</option>
<option value="27" style="color: initial;">Maine</option>
<option value="26" style="color: initial;">Maryland</option>
<option value="25" style="color: initial;">Massachusetts</option>
<option value="29" style="color: initial;">Michigan</option>
<option value="30" style="color: initial;">Minnesota</option>
<option value="33" style="color: initial;">Mississippi</option>
<option value="31" style="color: initial;">Missouri</option>
<option value="34" style="color: initial;">Montana</option>
<option value="37" style="color: initial;">Nebraska</option>
<option value="41" style="color: initial;">Nevada</option>
<option value="38" style="color: initial;">New Hampshire</option>
<option value="39" style="color: initial;">New Jersey</option>
<option value="40" style="color: initial;">New Mexico</option>
<option value="42" style="color: initial;">New York</option>
<option value="35" style="color: initial;">North Carolina</option>
<option value="36" style="color: initial;">North Dakota</option>
<option value="43" style="color: initial;">Ohio</option>
<option value="44" style="color: initial;">Oklahoma</option>
<option value="45" style="color: initial;">Oregon</option>
<option value="46" style="color: initial;">Pennsylvania</option>
<option value="49" style="color: initial;">Rhode Island</option>
<option value="50" style="color: initial;">South Carolina</option>
<option value="51" style="color: initial;">South Dakota</option>
<option value="52" style="color: initial;">Tennessee</option>
<option value="53" style="color: initial;">Texas</option>
<option value="54" style="color: initial;">Utah</option>
<option value="57" style="color: initial;">Vermont</option>
<option value="55" style="color: initial;">Virginia</option>
<option value="58" style="color: initial;">Washington</option>
<option value="59" style="color: initial;">West Virginia</option>
<option value="60" style="color: initial;">Wisconsin</option>
<option value="61" style="color: initial;">Wyoming</option>
<option value="6" style="color: initial;">American Samoa</option>
<option value="1" style="color: initial;">Armed Forces Europe, Middle East, & Canada</option>
<option value="4" style="color: initial;">Armed Forces Pacific</option>
<option value="62" style="color: initial;">Canada - Alberta</option>
<option value="63" style="color: initial;">Canada - British Columbia</option>
<option value="64" style="color: initial;">Canada - Manitoba</option>
<option value="65" style="color: initial;">Canada - New Brunswick</option>
<option value="66" style="color: initial;">Canada - Newfoundland</option>
<option value="73" style="color: initial;">Canada - Northwest Territories</option>
<option value="67" style="color: initial;">Canada - Nova Scotia</option>
<option value="68" style="color: initial;">Canada - Nunavut</option>
<option value="69" style="color: initial;">Canada - Ontario</option>
<option value="70" style="color: initial;">Canada - Prince Edward Island</option>
<option value="71" style="color: initial;">Canada - Quebec</option>
<option value="72" style="color: initial;">Canada - Saskatchewan</option>
<option value="74" style="color: initial;">Canada - Yukon Territory</option>
<option value="11" style="color: initial;">District of Columbia</option>
<option value="76" style="color: initial;">Federal Jurisdiction</option>
<option value="14" style="color: initial;">Federated States of Micronesia</option>
<option value="16" style="color: initial;">Guam</option>
<option value="28" style="color: initial;">Marshall Islands</option>
<option value="32" style="color: initial;">Northern Mariana Islands</option>
<option value="48" style="color: initial;">Palau</option>
<option value="47" style="color: initial;">Puerto Rico</option>
<option value="75" style="color: initial;">Unknown or Unspecified</option>
<option value="10001" style="color: initial;">USL&H</option>
<option value="56" style="color: initial;">Virgin Islands</option>
</select></span></li>
<li for="PostalCode" label="Accident Postal Code"><label for="PostalCode">Accident Postal Code: </label><span class="value"><input aria-label="Postal" class="medium textInput" id="PostalCode" maxlength="50" name="PostalCode"
type="text" value=""></span></li>
<li for="CountryID" label="Accident Country"><label for="CountryID">Accident Country: </label><span class="value"><select aria-label="Country" class="medium faded" data-fieldtype="Country" id="CountryID" name="CountryID">
<option value="" class="faded">- None Selected -</option>
<option value="3" style="color: initial;">Afghanistan</option>
<option value="6" style="color: initial;">Albania</option>
<option value="61" style="color: initial;">Algeria</option>
<option value="12" style="color: initial;">American Samoa</option>
<option value="1" style="color: initial;">Andorra</option>
<option value="9" style="color: initial;">Angola</option>
<option value="5" style="color: initial;">Anguilla</option>
<option value="10" style="color: initial;">Antarctica</option>
<option value="4" style="color: initial;">Antigua & Barbuda</option>
<option value="11" style="color: initial;">Argentina</option>
<option value="7" style="color: initial;">Armenia</option>
<option value="15" style="color: initial;">Aruba</option>
<option value="14" style="color: initial;">Australia</option>
<option value="13" style="color: initial;">Austria</option>
<option value="16" style="color: initial;">Azerbaijan</option>
<option value="30" style="color: initial;">Bahama</option>
<option value="23" style="color: initial;">Bahrain</option>
<option value="19" style="color: initial;">Bangladesh</option>
<option value="18" style="color: initial;">Barbados</option>
<option value="35" style="color: initial;">Belarus</option>
<option value="20" style="color: initial;">Belgium</option>
<option value="36" style="color: initial;">Belize</option>
<option value="25" style="color: initial;">Benin</option>
<option value="26" style="color: initial;">Bermuda</option>
<option value="31" style="color: initial;">Bhutan</option>
<option value="28" style="color: initial;">Bolivia</option>
<option value="17" style="color: initial;">Bosnia and Herzegovina</option>
<option value="34" style="color: initial;">Botswana</option>
<option value="33" style="color: initial;">Bouvet Island</option>
<option value="29" style="color: initial;">Brazil</option>
<option value="104" style="color: initial;">British Indian Ocean Territory</option>
<option value="231" style="color: initial;">British Virgin Islands</option>
<option value="27" style="color: initial;">Brunei Darussalam</option>
<option value="22" style="color: initial;">Bulgaria</option>
<option value="21" style="color: initial;">Burkina Faso</option>
<option value="32" style="color: initial;">Burma (no longer exists)</option>
<option value="24" style="color: initial;">Burundi</option>
<option value="114" style="color: initial;">Cambodia</option>
<option value="45" style="color: initial;">Cameroon</option>
<option value="37" style="color: initial;">Canada</option>
<option value="51" style="color: initial;">Cape Verde</option>
<option value="121" style="color: initial;">Cayman Islands</option>
<option value="39" style="color: initial;">Central African Republic</option>
<option value="207" style="color: initial;">Chad</option>
<option value="44" style="color: initial;">Chile</option>
<option value="46" style="color: initial;">China</option>
<option value="52" style="color: initial;">Christmas Island</option>
<option value="38" style="color: initial;">Cocos (Keeling) Islands</option>
<option value="47" style="color: initial;">Colombia</option>
<option value="116" style="color: initial;">Comoros</option>
<option value="40" style="color: initial;">Congo</option>
<option value="43" style="color: initial;">Cook Islands</option>
<option value="48" style="color: initial;">Costa Rica</option>
<option value="42" style="color: initial;">Cote d'Ivoire (Ivory Coast)</option>
<option value="97" style="color: initial;">Croatia</option>
<option value="50" style="color: initial;">Cuba</option>
<option value="53" style="color: initial;">Cyprus</option>
<option value="54" style="color: initial;">Czech Republic</option>
<option value="49" style="color: initial;">Czechoslovakia (no longer exists)</option>
<option value="237" style="color: initial;">Democratic Yemen (no longer exists)</option>
<option value="58" style="color: initial;">Denmark</option>
<option value="57" style="color: initial;">Djibouti</option>
<option value="59" style="color: initial;">Dominica</option>
<option value="60" style="color: initial;">Dominican Republic</option>
<option value="216" style="color: initial;">East Timor</option>
<option value="62" style="color: initial;">Ecuador</option>
<option value="64" style="color: initial;">Egypt</option>
<option value="203" style="color: initial;">El Salvador</option>
<option value="87" style="color: initial;">Equatorial Guinea</option>
<option value="66" style="color: initial;">Eritrea</option>
<option value="63" style="color: initial;">Estonia</option>
<option value="68" style="color: initial;">Ethiopia</option>
<option value="71" style="color: initial;">Falkland Islands (Malvinas)</option>
<option value="73" style="color: initial;">Faroe Islands</option>
<option value="70" style="color: initial;">Fiji</option>
<option value="69" style="color: initial;">Finland</option>
<option value="74" style="color: initial;">France</option>
<option value="75" style="color: initial;">France, Metropolitan</option>
<option value="80" style="color: initial;">French Guiana</option>
<option value="170" style="color: initial;">French Polynesia</option>
<option value="208" style="color: initial;">French Southern Territories</option>
<option value="76" style="color: initial;">Gabon</option>
<option value="84" style="color: initial;">Gambia</option>
<option value="79" style="color: initial;">Georgia</option>
<option value="55" style="color: initial;">German Democratic Republic (no longer exists)</option>
<option value="56" style="color: initial;">Germany</option>
<option value="81" style="color: initial;">Ghana</option>
<option value="82" style="color: initial;">Gibraltar</option>
<option value="88" style="color: initial;">Greece</option>
<option value="83" style="color: initial;">Greenland</option>
<option value="78" style="color: initial;">Grenada</option>
<option value="86" style="color: initial;">Guadeloupe</option>
<option value="91" style="color: initial;">Guam</option>
<option value="90" style="color: initial;">Guatemala</option>
<option value="85" style="color: initial;">Guinea</option>
<option value="92" style="color: initial;">Guinea-Bissau</option>
<option value="93" style="color: initial;">Guyana</option>
<option value="98" style="color: initial;">Haiti</option>
<option value="95" style="color: initial;">Heard & McDonald Islands</option>
<option value="96" style="color: initial;">Honduras</option>
<option value="94" style="color: initial;">Hong Kong</option>
<option value="99" style="color: initial;">Hungary</option>
<option value="107" style="color: initial;">Iceland</option>
<option value="103" style="color: initial;">India</option>
<option value="100" style="color: initial;">Indonesia</option>
<option value="105" style="color: initial;">Iraq</option>
<option value="101" style="color: initial;">Ireland</option>
<option value="106" style="color: initial;">Islamic Republic of Iran</option>
<option value="102" style="color: initial;">Israel</option>
<option value="108" style="color: initial;">Italy</option>
<option value="109" style="color: initial;">Jamaica</option>
<option value="111" style="color: initial;">Japan</option>
<option value="110" style="color: initial;">Jordan</option>
<option value="122" style="color: initial;">Kazakhstan</option>
<option value="112" style="color: initial;">Kenya</option>
<option value="115" style="color: initial;">Kiribati</option>
<option value="118" style="color: initial;">Korea, Democratic People's Republic of</option>
<option value="119" style="color: initial;">Korea, Republic of</option>
<option value="120" style="color: initial;">Kuwait</option>
<option value="113" style="color: initial;">Kyrgyzstan</option>
<option value="123" style="color: initial;">Lao People's Democratic Republic</option>
<option value="132" style="color: initial;">Latvia</option>
<option value="124" style="color: initial;">Lebanon</option>
<option value="129" style="color: initial;">Lesotho</option>
<option value="128" style="color: initial;">Liberia</option>
<option value="133" style="color: initial;">Libyan Arab Jamahiriya</option>
<option value="126" style="color: initial;">Liechtenstein</option>
<option value="130" style="color: initial;">Lithuania</option>
<option value="131" style="color: initial;">Luxembourg</option>
<option value="142" style="color: initial;">Macau</option>
<option value="137" style="color: initial;">Madagascar</option>
<option value="150" style="color: initial;">Malawi</option>
<option value="152" style="color: initial;">Malaysia</option>
<option value="149" style="color: initial;">Maldives</option>
<option value="139" style="color: initial;">Mali</option>
<option value="147" style="color: initial;">Malta</option>
<option value="138" style="color: initial;">Marshall Islands</option>
<option value="144" style="color: initial;">Martinique</option>
<option value="145" style="color: initial;">Mauritania</option>
<option value="148" style="color: initial;">Mauritius</option>
<option value="239" style="color: initial;">Mayotte</option>
<option value="151" style="color: initial;">Mexico</option>
<option value="72" style="color: initial;">Micronesia</option>
<option value="136" style="color: initial;">Moldova, Republic of</option>
<option value="135" style="color: initial;">Monaco</option>
<option value="140" style="color: initial;">Mongolia</option>
<option value="146" style="color: initial;">Monserrat</option>
<option value="134" style="color: initial;">Morocco</option>
<option value="153" style="color: initial;">Mozambique</option>
<option value="141" style="color: initial;">Myanmar</option>
<option value="154" style="color: initial;">Namibia</option>
<option value="163" style="color: initial;">Nauru</option>
<option value="162" style="color: initial;">Nepal</option>
<option value="160" style="color: initial;">Netherlands</option>
<option value="8" style="color: initial;">Netherlands Antilles</option>
<option value="164" style="color: initial;">Neutral Zone (no longer exists)</option>
<option value="155" style="color: initial;">New Caledonia</option>
<option value="166" style="color: initial;">New Zealand</option>
<option value="159" style="color: initial;">Nicaragua</option>
<option value="156" style="color: initial;">Niger</option>
<option value="158" style="color: initial;">Nigeria</option>
<option value="165" style="color: initial;">Niue</option>
<option value="157" style="color: initial;">Norfolk Island</option>
<option value="143" style="color: initial;">Northern Mariana Islands</option>
<option value="161" style="color: initial;">Norway</option>
<option value="167" style="color: initial;">Oman</option>
<option value="173" style="color: initial;">Pakistan</option>
<option value="179" style="color: initial;">Palau</option>
<option value="168" style="color: initial;">Panama</option>
<option value="171" style="color: initial;">Papua New Guinea</option>
<option value="180" style="color: initial;">Paraguay</option>
<option value="169" style="color: initial;">Peru</option>
<option value="172" style="color: initial;">Philippines</option>
<option value="176" style="color: initial;">Pitcairn</option>
<option value="174" style="color: initial;">Poland</option>
<option value="178" style="color: initial;">Portugal</option>
<option value="177" style="color: initial;">Puerto Rico</option>
<option value="181" style="color: initial;">Qatar</option>
<option value="183" style="color: initial;">Romania</option>
<option value="182" style="color: initial;">RTunion</option>
<option value="184" style="color: initial;">Russian Federation</option>
<option value="185" style="color: initial;">Rwanda</option>
<option value="125" style="color: initial;">Saint Lucia</option>
<option value="236" style="color: initial;">Samoa</option>
<option value="197" style="color: initial;">San Marino</option>
<option value="201" style="color: initial;">Sao Tome & Principe</option>
<option value="186" style="color: initial;">Saudi Arabia</option>
<option value="198" style="color: initial;">Senegal</option>
<option value="188" style="color: initial;">Seychelles</option>
<option value="196" style="color: initial;">Sierra Leone</option>
<option value="191" style="color: initial;">Singapore</option>
<option value="195" style="color: initial;">Slovakia</option>
<option value="193" style="color: initial;">Slovenia</option>
<option value="187" style="color: initial;">Solomon Islands</option>
<option value="199" style="color: initial;">Somalia</option>
<option value="241" style="color: initial;">South Africa</option>
<option value="89" style="color: initial;">South Georgia and the South Sandwich Islands</option>
<option value="67" style="color: initial;">Spain</option>
<option value="127" style="color: initial;">Sri Lanka</option>
<option value="192" style="color: initial;">St. Helena</option>
<option value="117" style="color: initial;">St. Kitts and Nevis</option>
<option value="175" style="color: initial;">St. Pierre & Miquelon</option>
<option value="229" style="color: initial;">St. Vincent & the Grenadines</option>
<option value="189" style="color: initial;">Sudan</option>
<option value="200" style="color: initial;">Suriname</option>
<option value="194" style="color: initial;">Svalbard & Jan Mayen Islands</option>
<option value="205" style="color: initial;">Swaziland</option>
<option value="190" style="color: initial;">Sweden</option>
<option value="41" style="color: initial;">Switzerland</option>
<option value="204" style="color: initial;">Syrian Arab Republic</option>
<option value="220" style="color: initial;">Taiwan, Province of China</option>
<option value="211" style="color: initial;">Tajikistan</option>
<option value="221" style="color: initial;">Tanzania, United Republic of</option>
<option value="210" style="color: initial;">Thailand</option>
<option value="209" style="color: initial;">Togo</option>
<option value="212" style="color: initial;">Tokelau</option>
<option value="215" style="color: initial;">Tonga</option>
<option value="218" style="color: initial;">Trinidad & Tobago</option>
<option value="214" style="color: initial;">Tunisia</option>
<option value="217" style="color: initial;">Turkey</option>
<option value="213" style="color: initial;">Turkmenistan</option>
<option value="206" style="color: initial;">Turks & Caicos Islands</option>
<option value="219" style="color: initial;">Tuvalu</option>
<option value="223" style="color: initial;">Uganda</option>
<option value="222" style="color: initial;">Ukraine</option>
<option value="202" style="color: initial;">Union of Soviet Socialist Republics (no longer exists)</option>
<option value="2" style="color: initial;">United Arab Emirates</option>
<option value="77" style="color: initial;">United Kingdom (Great Britain)</option>
<option value="224" style="color: initial;">United States Minor Outlying Islands</option>
<option value="225" style="color: initial;">United States of America</option>
<option value="232" style="color: initial;">United States Virgin Islands</option>
<option value="245" style="color: initial;">Unknown or unspecified country</option>
<option value="226" style="color: initial;">Uruguay</option>
<option value="227" style="color: initial;">Uzbekistan</option>
<option value="234" style="color: initial;">Vanuatu</option>
<option value="228" style="color: initial;">Vatican City State (Holy See)</option>
<option value="230" style="color: initial;">Venezuela</option>
<option value="233" style="color: initial;">Viet Nam</option>
<option value="235" style="color: initial;">Wallis & Futuna Islands</option>
<option value="65" style="color: initial;">Western Sahara</option>
<option value="238" style="color: initial;">Yemen</option>
<option value="240" style="color: initial;">Yugoslavia</option>
<option value="243" style="color: initial;">Zaire</option>
<option value="242" style="color: initial;">Zambia</option>
<option value="244" style="color: initial;">Zimbabwe</option>
</select></span></li>
<li for="CustomNarrative5" label="Equipment, Materials, or Chemicals Used:"><label for="CustomNarrative5">Equipment, Materials, or Chemicals Used:</label><span class="value"><textarea aria-label="Object Causing Injury" class="large"
cols="20" id="CustomNarrative5" maxlength="" name="CustomNarrative5" rows="2"></textarea></span></li>
</ul>
</div>
</div>
</div>
<div aria-labelledby="title_TreatmentInformation" class="panel yui-g" role="region">
<h3 id="title_TreatmentInformation" tabindex="-1">Treatment Information</h3>
<div class="yui-u first">
<div class="section">
<ul class="properties wideLabels ">
<li for="CustomCode20ID" label="Initial Treatment Code"><label for="CustomCode20ID">Initial Treatment Code: </label><span class="value"><select aria-label="Initial Treatment Code" class="medium faded" data-codetypeid="10250"
data-fieldtype="Code" id="CustomCode20ID" name="CustomCode20ID">
<option value="" class="faded">- None Selected -</option>
<option value="18527" style="color: initial;">Trauma/ICU</option>
<option value="18526" style="color: initial;">Hospitalized</option>
<option value="18525" style="color: initial;">ER Visit</option>
<option value="18524" style="color: initial;">Urgent Care Visit</option>
<option value="18523" style="color: initial;">Minor Medical</option>
<option value="18522" style="color: initial;">No Treatment</option>
</select></span></li>
<li for="CustomText36" label="Urgent Care or Hospital Name"><label for="CustomText36">Urgent Care or Hospital Name: </label><span class="value"><input aria-label="Hospital Name" class="large medium textInput" id="CustomText36"
maxlength="256" name="CustomText36" placeholder="Healthcare system or Facility Name" type="text" value=""></span></li>
<li for="CustomText38" label="Hospital Address"><label for="CustomText38">Hospital Address: </label><span class="value"><input aria-label="Hospital Street1" class="large medium textInput" id="CustomText38" maxlength="256"
name="CustomText38" placeholder="ex. 123 Main St." type="text" value=""></span></li>
<li for="CustomText39" label="Hospital City"><label for="CustomText39">Hospital City: </label><span class="value"><input aria-label="Hospital City" class="medium textInput" id="CustomText39" maxlength="256" name="CustomText39"
type="text" value=""></span></li>
<li for="CustomCode21ID" label="Hospital State"><label for="CustomCode21ID">Hospital State: </label><span class="value"><select aria-label="Hospital State" class="medium faded" data-codetypeid="10002" data-fieldtype="Code"
id="CustomCode21ID" name="CustomCode21ID">
<option value="" class="faded">- None Selected -</option>
<option value="10164" style="color: initial;">Alabama</option>
<option value="10163" style="color: initial;">Alaska</option>
<option value="10166" style="color: initial;">Arizona</option>
<option value="10165" style="color: initial;">Arkansas</option>
<option value="10167" style="color: initial;">California</option>
<option value="10168" style="color: initial;">Colorado</option>
<option value="10169" style="color: initial;">Connecticut</option>
<option value="10171" style="color: initial;">Delaware</option>
<option value="10172" style="color: initial;">Florida</option>
<option value="10173" style="color: initial;">Georgia</option>
<option value="10174" style="color: initial;">Hawaii</option>
<option value="10176" style="color: initial;">Idaho</option>
<option value="10177" style="color: initial;">Illinois</option>
<option value="10178" style="color: initial;">Indiana</option>
<option value="10175" style="color: initial;">Iowa</option>
<option value="10179" style="color: initial;">Kansas</option>
<option value="10180" style="color: initial;">Kentucky</option>
<option value="10181" style="color: initial;">Louisiana</option>
<option value="10184" style="color: initial;">Maine</option>
<option value="10183" style="color: initial;">Maryland</option>
<option value="10182" style="color: initial;">Massachusetts</option>
<option value="10185" style="color: initial;">Michigan</option>
<option value="10186" style="color: initial;">Minnesota</option>
<option value="10188" style="color: initial;">Mississippi</option>
<option value="10187" style="color: initial;">Missouri</option>
<option value="10189" style="color: initial;">Montana</option>
<option value="10192" style="color: initial;">Nebraska</option>
<option value="10196" style="color: initial;">Nevada</option>
<option value="10193" style="color: initial;">New Hampshire</option>
<option value="10194" style="color: initial;">New Jersey</option>
<option value="10195" style="color: initial;">New Mexico</option>
<option value="10197" style="color: initial;">New York</option>
<option value="10190" style="color: initial;">North Carolina</option>
<option value="10191" style="color: initial;">North Dakota</option>
<option value="10198" style="color: initial;">Ohio</option>
<option value="10199" style="color: initial;">Oklahoma</option>
<option value="10200" style="color: initial;">Oregon</option>
<option value="10201" style="color: initial;">Pennsylvania</option>
<option value="10202" style="color: initial;">Rhode Island</option>
<option value="10203" style="color: initial;">South Carolina</option>
<option value="10204" style="color: initial;">South Dakota</option>
<option value="10205" style="color: initial;">Tennessee</option>
<option value="10206" style="color: initial;">Texas</option>
<option value="10207" style="color: initial;">Utah</option>
<option value="10209" style="color: initial;">Vermont</option>
<option value="10208" style="color: initial;">Virginia</option>
<option value="10210" style="color: initial;">Washington</option>
<option value="10212" style="color: initial;">West Virginia</option>
<option value="10211" style="color: initial;">Wisconsin</option>
<option value="10213" style="color: initial;">Wyoming</option>
<option value="14271" style="color: initial;">American Samoa</option>
<option value="14269" style="color: initial;">Armed Forces Europe, Middle East, & Canada</option>
<option value="14270" style="color: initial;">Armed Forces Pacific</option>
<option value="14279" style="color: initial;">Canada - Alberta</option>
<option value="14280" style="color: initial;">Canada - British Columbia</option>
<option value="14281" style="color: initial;">Canada - Manitoba</option>
<option value="14282" style="color: initial;">Canada - New Brunswick</option>
<option value="14290" style="color: initial;">Canada - Northwest Territories</option>
<option value="14283" style="color: initial;">Canada - Newfoundland</option>
<option value="14284" style="color: initial;">Canada - Nova Scotia</option>
<option value="14285" style="color: initial;">Canada - Nunavut</option>
<option value="14286" style="color: initial;">Canada - Ontario</option>
<option value="14287" style="color: initial;">Canada - Prince Edward Island</option>
<option value="14288" style="color: initial;">Canada - Quebec</option>
<option value="14289" style="color: initial;">Canada - Saskatchewan</option>
<option value="14291" style="color: initial;">Canada - Yukon Territory</option>
<option value="10170" style="color: initial;">District of Columbia</option>
<option value="14292" style="color: initial;">Federal Jurisdiction</option>
<option value="14272" style="color: initial;">Federated States of Micronesia</option>
<option value="14273" style="color: initial;">Guam</option>
<option value="14274" style="color: initial;">Marshall Islands</option>
<option value="14275" style="color: initial;">Northern Mariana Islands</option>
<option value="14277" style="color: initial;">Palau</option>
<option value="14276" style="color: initial;">Puerto Rico</option>
<option value="10214" style="color: initial;">Unknown or Unspecified</option>
<option value="14278" style="color: initial;">Virgin Islands</option>
</select></span></li>
<li for="CustomText40" label="Hospital Postal Code"><label for="CustomText40">Hospital Postal Code: </label><span class="value"><input aria-label="Hospital Postal Code" class="medium textInput" id="CustomText40" maxlength="256"
name="CustomText40" type="text" value=""></span></li>
<li for="CustomText41" label="Hospital Telephone"><label for="CustomText41">Hospital Telephone: </label><span class="value"><input aria-label="Hospital Telephone" class="phoneNumber medium textInput" id="CustomText41"
instructions="Enter digits for 'US' or type + for international numbers." maxlength="256" name="CustomText41" phone-defaultcountry="US" type="text" value=""> <span class="faded">ext</span> <input
aria-label="Hospital Telephone Extension" class="phoneExtension medium textInput" maxlength="256" name="__phoneExt_CustomText41" type="text" value=""></span><span class="value faded instructions">Enter digits for 'US' or type +
for international numbers.</span></li>
</ul>
</div>
</div>
<div class="yui-u doric">
<div class="section">
<ul class="properties wideLabels ">
<li for="CustomText42" label="Treating Physician Name:"><label for="CustomText42">Treating Physician Name:</label><span class="value"><input aria-label="Physician Name" class="medium textInput" id="CustomText42" maxlength="256"
name="CustomText42" type="text" value=""></span></li>
<li for="CustomText43" label="Name of Practice"><label for="CustomText43">Name of Practice: </label><span class="value"><input aria-label="Name of Practice" class="medium textInput" id="CustomText43" maxlength="256"
name="CustomText43" type="text" value=""></span></li>
<li for="CustomText44" label="Physician Address"><label for="CustomText44">Physician Address: </label><span class="value"><input aria-label="Physician Address" class="medium textInput" id="CustomText44" maxlength="256"
name="CustomText44" type="text" value=""></span></li>
<li for="CustomText45" label="Physician City"><label for="CustomText45">Physician City: </label><span class="value"><input aria-label="Physician City" class="medium textInput" id="CustomText45" maxlength="256" name="CustomText45"
type="text" value=""></span></li>
<li for="CustomCode22ID" label="Physician State"><label for="CustomCode22ID">Physician State: </label><span class="value"><select aria-label="Physician State" class="medium faded" data-codetypeid="10002" data-fieldtype="Code"
id="CustomCode22ID" name="CustomCode22ID">
<option value="" class="faded">- None Selected -</option>
<option value="10164" style="color: initial;">Alabama</option>
<option value="10163" style="color: initial;">Alaska</option>
<option value="10166" style="color: initial;">Arizona</option>
<option value="10165" style="color: initial;">Arkansas</option>
<option value="10167" style="color: initial;">California</option>
<option value="10168" style="color: initial;">Colorado</option>
<option value="10169" style="color: initial;">Connecticut</option>
<option value="10171" style="color: initial;">Delaware</option>
<option value="10172" style="color: initial;">Florida</option>
<option value="10173" style="color: initial;">Georgia</option>
<option value="10174" style="color: initial;">Hawaii</option>
<option value="10176" style="color: initial;">Idaho</option>
<option value="10177" style="color: initial;">Illinois</option>
<option value="10178" style="color: initial;">Indiana</option>
<option value="10175" style="color: initial;">Iowa</option>
<option value="10179" style="color: initial;">Kansas</option>
<option value="10180" style="color: initial;">Kentucky</option>
<option value="10181" style="color: initial;">Louisiana</option>
<option value="10184" style="color: initial;">Maine</option>
<option value="10183" style="color: initial;">Maryland</option>
<option value="10182" style="color: initial;">Massachusetts</option>
<option value="10185" style="color: initial;">Michigan</option>
<option value="10186" style="color: initial;">Minnesota</option>
<option value="10188" style="color: initial;">Mississippi</option>
<option value="10187" style="color: initial;">Missouri</option>
<option value="10189" style="color: initial;">Montana</option>
<option value="10192" style="color: initial;">Nebraska</option>
<option value="10196" style="color: initial;">Nevada</option>
<option value="10193" style="color: initial;">New Hampshire</option>
<option value="10194" style="color: initial;">New Jersey</option>
<option value="10195" style="color: initial;">New Mexico</option>
<option value="10197" style="color: initial;">New York</option>
<option value="10190" style="color: initial;">North Carolina</option>
<option value="10191" style="color: initial;">North Dakota</option>
<option value="10198" style="color: initial;">Ohio</option>
<option value="10199" style="color: initial;">Oklahoma</option>
<option value="10200" style="color: initial;">Oregon</option>
<option value="10201" style="color: initial;">Pennsylvania</option>
<option value="10202" style="color: initial;">Rhode Island</option>
<option value="10203" style="color: initial;">South Carolina</option>
<option value="10204" style="color: initial;">South Dakota</option>
<option value="10205" style="color: initial;">Tennessee</option>
<option value="10206" style="color: initial;">Texas</option>
<option value="10207" style="color: initial;">Utah</option>
<option value="10209" style="color: initial;">Vermont</option>
<option value="10208" style="color: initial;">Virginia</option>
<option value="10210" style="color: initial;">Washington</option>
<option value="10212" style="color: initial;">West Virginia</option>
<option value="10211" style="color: initial;">Wisconsin</option>
<option value="10213" style="color: initial;">Wyoming</option>
<option value="14271" style="color: initial;">American Samoa</option>
<option value="14269" style="color: initial;">Armed Forces Europe, Middle East, & Canada</option>
<option value="14270" style="color: initial;">Armed Forces Pacific</option>
<option value="14279" style="color: initial;">Canada - Alberta</option>
<option value="14280" style="color: initial;">Canada - British Columbia</option>
<option value="14281" style="color: initial;">Canada - Manitoba</option>
<option value="14282" style="color: initial;">Canada - New Brunswick</option>
<option value="14290" style="color: initial;">Canada - Northwest Territories</option>
<option value="14283" style="color: initial;">Canada - Newfoundland</option>
<option value="14284" style="color: initial;">Canada - Nova Scotia</option>
<option value="14285" style="color: initial;">Canada - Nunavut</option>
<option value="14286" style="color: initial;">Canada - Ontario</option>
<option value="14287" style="color: initial;">Canada - Prince Edward Island</option>
<option value="14288" style="color: initial;">Canada - Quebec</option>
<option value="14289" style="color: initial;">Canada - Saskatchewan</option>
<option value="14291" style="color: initial;">Canada - Yukon Territory</option>
<option value="10170" style="color: initial;">District of Columbia</option>
<option value="14292" style="color: initial;">Federal Jurisdiction</option>
<option value="14272" style="color: initial;">Federated States of Micronesia</option>
<option value="14273" style="color: initial;">Guam</option>
<option value="14274" style="color: initial;">Marshall Islands</option>
<option value="14275" style="color: initial;">Northern Mariana Islands</option>
<option value="14277" style="color: initial;">Palau</option>
<option value="14276" style="color: initial;">Puerto Rico</option>
<option value="10214" style="color: initial;">Unknown or Unspecified</option>
<option value="14278" style="color: initial;">Virgin Islands</option>
</select></span></li>
<li for="CustomText46" label="Physician Postal Code"><label for="CustomText46">Physician Postal Code: </label><span class="value"><input aria-label="Physician Postal Code" class="medium textInput" id="CustomText46"
maxlength="256" name="CustomText46" type="text" value=""></span></li>
<li for="CustomText47" label="Physician Telephone"><label for="CustomText47">Physician Telephone: </label><span class="value"><input aria-label="Physician Telephone" class="phoneNumber medium textInput" id="CustomText47"
instructions="Enter digits for 'US' or type + for international numbers." maxlength="256" name="CustomText47" phone-defaultcountry="US" type="text" value=""> <span class="faded">ext</span> <input
aria-label="Physician Telephone Extension" class="phoneExtension medium textInput" maxlength="256" name="__phoneExt_CustomText47" type="text" value=""></span><span class="value faded instructions">Enter digits for 'US' or type +
for international numbers.</span></li>
</ul>
</div>
</div>
</div>
<div aria-labelledby="title_OtherInformation" class="panel yui-g" role="region">
<h3 id="title_OtherInformation" tabindex="-1">Other Information</h3>
<div class="yui-u first">
<div class="section">
<ul class="properties wideLabels ">
<li class="required" for="CustomText48" label="Claim being reported by"><label class="required" for="CustomText48" title="Claim being reported by. Required field.">Claim being reported by: </label><span class="value"><input
aria-label="Reported By" aria-required="true" class="medium textInput" id="CustomText48" maxlength="256" name="CustomText48" type="text" value=""></span></li>
<li for="CustomText49" label="Company"><label for="CustomText49">Company: </label><span class="value"><input aria-label="Reported By Company Name" class="medium textInput" id="CustomText49" maxlength="256" name="CustomText49"
type="text" value=""></span></li>
<li for="CustomText50" label="Title"><label for="CustomText50">Title: </label><span class="value"><input aria-label="Reported By Title" class="medium textInput" id="CustomText50" maxlength="256" name="CustomText50" type="text"
value=""></span></li>
<li class="required" for="CustomText51" label="Telephone Number"><label class="required" for="CustomText51" title="Telephone Number. Required field.">Telephone Number: </label><span class="value"><input
aria-label="Reported By Telephone" aria-required="true" class="phoneNumber medium textInput" id="CustomText51" instructions="Enter digits for 'US' or type + for international numbers." maxlength="256" name="CustomText51"
phone-defaultcountry="US" type="text" value=""> <span class="faded">ext</span> <input aria-label="Reported By Telephone Extension" class="phoneExtension medium textInput" maxlength="256"
name="__phoneExt_CustomText51" type="text" value=""></span><span class="value faded instructions">Enter digits for 'US' or type + for international numbers.</span></li>
<li class="required" for="CustomText52" label="Email Address"><label class="required" for="CustomText52" title="Email Address. Required field.">Email Address: </label><span class="value"><input aria-label="Reported By Email"
aria-required="true" class="medium textInput" id="CustomText52" maxlength="256" name="CustomText52" type="text" value=""></span></li>
<li class="required" for="CustomText105" label="Email Address Verify"><label class="required" for="CustomText105" title="Email Address Verify. Required field.">Email Address Verify: </label><span class="value"><input
aria-label="Contact Email Verify" aria-required="true" class="medium textInput" id="CustomText105" maxlength="256" name="CustomText105" type="text" value=""></span></li>
<li for="CustomBool21" label="Contact Same as Reporter"><label for="CustomBool21">Contact Same as Reporter: </label><span class="value"><select aria-label="Contact Same as Reporter" id="CustomBool21" name="CustomBool21"
class="faded">
<option value="" class="faded">- None Selected -</option>
<option value="True" style="color: initial;">Yes</option>
<option value="False" style="color: initial;">No</option>
</select></span></li>
<li for="CustomText53" label="Contact Name"><label for="CustomText53">Contact Name: </label><span class="value"><input aria-label="Who Should Examiner Contact" class="medium textInput" id="CustomText53" maxlength="256"
name="CustomText53" type="text" value=""></span></li>
<li class="required" for="CustomText94" label="Contact Email"><label class="required" for="CustomText94" title="Contact Email. Required field.">Contact Email: </label><span class="value"><input aria-label="To Be Contacted Email"
aria-required="true" class="medium textInput" id="CustomText94" maxlength="256" name="CustomText94" type="text" value=""></span></li>
<li class="required" for="CustomText106" label="Contact Email Verify"><label class="required" for="CustomText106" title="Contact Email Verify. Required field.">Contact Email Verify: </label><span class="value"><input
aria-label="To Be Contacted Email Verify" aria-required="true" class="medium textInput" id="CustomText106" maxlength="256" name="CustomText106" type="text" value=""></span></li>
<li for="CustomText95" label="Contact Phone"><label for="CustomText95">Contact Phone: </label><span class="value"><input aria-label="To Be Contacted Phone" class="phoneNumber medium textInput" id="CustomText95"
instructions="Enter digits for 'US' or type + for international numbers." maxlength="256" name="CustomText95" phone-defaultcountry="US" type="text" value=""> <span class="faded">ext</span> <input
aria-label="To Be Contacted Phone Extension" class="phoneExtension medium textInput" maxlength="256" name="__phoneExt_CustomText95" type="text" value=""></span><span class="value faded instructions">Enter digits for 'US' or type
+ for international numbers.</span></li>
</ul>
</div>
</div>
<div class="yui-u doric">
<div class="section">
<ul class="properties wideLabels ">
<li for="CustomBool13" label="Were there any witnesses?"><label for="CustomBool13">Were there any witnesses?</label><span class="value"><select aria-label="Were There Any Witnesses" id="CustomBool13" name="CustomBool13" class="faded">
<option value="" class="faded">- None Selected -</option>
<option value="True" style="color: initial;">Yes</option>
<option value="False" style="color: initial;">No</option>
</select></span></li>
<li for="CustomText54" label="Witness"><label for="CustomText54">Witness: </label><span class="value"><input aria-label="Witness" class="medium textInput" id="CustomText54" maxlength="256" name="CustomText54" type="text"
value=""></span></li>
<li for="CustomText55" label="Telephone Number"><label for="CustomText55">Telephone Number: </label><span class="value"><input aria-label="Witness Telephone" class="phoneNumber medium textInput" id="CustomText55"
instructions="Enter digits for 'US' or type + for international numbers." maxlength="256" name="CustomText55" phone-defaultcountry="US" type="text" value=""> <span class="faded">ext</span> <input
aria-label="Witness Telephone Extension" class="phoneExtension medium textInput" maxlength="256" name="__phoneExt_CustomText55" type="text" value=""></span><span class="value faded instructions">Enter digits for 'US' or type +
for international numbers.</span></li>
</ul>
</div>
</div>
</div>
<input type="hidden" id="_OrigamiFormRequiredFields" name="_OrigamiFormRequiredFields" value="" aria-label="_OrigamiFormRequiredFields"><input type="hidden" id="_OrigamiFormRequiredFormulaMessages" name="_OrigamiFormRequiredFormulaMessages"
value="" aria-label="_OrigamiFormRequiredFormulaMessages"><input type="hidden" id="_OrigamiFormDefaultValuesSet" name="_OrigamiFormDefaultValuesSet" value=",Custom4Code,CustomBool55,CustomBool8"
aria-label="_OrigamiFormDefaultValuesSet"><input type="hidden" name="formVariables"
value="[{"Key":"Alias_EventPolicy","Value":null},{"Key":"Alias_Event_ClaimantFirst","Value":null},{"Key":"Alias_Event_ClaimantLast","Value":null},{"Key":"Alias_Event_ClaimantEmail","Value":null},{"Key":"Alias_LossEvent_BirthDate","Value":null}]"
aria-label="formVariables">
<script src="/content/scripts/formformulas.js?v=d6d961dd1f3ee592bfeef22e4beca64b" type="text/javascript"></script><input type="hidden" name="customFieldAliases"
value="[{"Alias":"Event_ClaimantAddress1","Field":"CustomText2"},{"Alias":"Event_ClaimantAddress2","Field":"CustomText3"},{"Alias":"Event_ClaimantCity","Field":"CustomText4"},{"Alias":"Event_ClaimantPostal","Field":"CustomText5"},{"Alias":"Event_ClaimantEmail","Field":"CustomText6"},{"Alias":"Event_ClaimantPhone","Field":"CustomText7"},{"Alias":"Event_ClaimantState","Field":"Custom1Code"},{"Alias":"Event_PoliceDepartment","Field":"CustomText8"},{"Alias":"Event_PoliceReportNumber","Field":"CustomText9"},{"Alias":"Event_PoliceInvolved","Field":"CustomBool1"},{"Alias":"Event_InsuredVehicleMake","Field":"CustomText10"},{"Alias":"Event_InsuredVehicleModel","Field":"CustomText11"},{"Alias":"Event_InsuredVehicleVIN","Field":"CustomText12"},{"Alias":"Event_VehicleTag","Field":"CustomText13"},{"Alias":"Event_ClaimantFirst","Field":"CustomText14"},{"Alias":"Event_ClaimantLast","Field":"CustomText15"},{"Alias":"Event_ClaimantFull","Field":"CustomText16"},{"Alias":"Event_VehicleYear","Field":"Custom2Code"},{"Alias":"Event_AirbagDeploy","Field":"CustomBool3"},{"Alias":"Event_RolloverStatus","Field":"CustomBool4"},{"Alias":"Event_InsuredVehicleAge","Field":"CustomNumber1"},{"Alias":"Event_OdometerReading","Field":"CustomNumber2"},{"Alias":"Event_VehiclePolicyIndicator","Field":"CustomBool2"},{"Alias":"Event_AccidentLocationInformation","Field":"CustomNarrative1"},{"Alias":"Event_LossDescription","Field":"CustomNarrative2"},{"Alias":"Event_MemberID","Field":"CustomText17"},{"Alias":"EventPolicy","Field":"CustomText1"},{"Alias":"HMIGFNOLPolicyID","Field":"CustomText18"},{"Alias":"LE_HMIGSource","Field":"Custom3Code"},{"Alias":"LossEvents_HMIGProductCode","Field":"CustomText20"},{"Alias":"LossEvent_IntakeCode","Field":"Custom4Code"},{"Alias":"LossEvent_NamedInsured","Field":"CustomText19"},{"Alias":"LossEvent_NamedInsuredStreet1","Field":"CustomText21"},{"Alias":"LossEvent_NamedInsuredStreet2","Field":"CustomText22"},{"Alias":"LossEvent_NamedInsuredCity","Field":"CustomText23"},{"Alias":"LossEvent_NamedInsuredState","Field":"Custom5Code"},{"Alias":"LossEvent_NamedInsuredPostalCode","Field":"CustomText24"},{"Alias":"LossEvent_NamedInsuredFEIN","Field":"CustomText25"},{"Alias":"LossEvent_NamedInsuredIndustryCode","Field":"CustomText26"},{"Alias":"LossEvent_EmployerLocationAddressIfDifferent","Field":"CustomNarrative3"},{"Alias":"LossEvent_EmployerContactName","Field":"CustomText27"},{"Alias":"LossEvent_EmployerTelephone","Field":"CustomText28"},{"Alias":"LossEvent_EmployerEmail","Field":"CustomText29"},{"Alias":"LossEvent_InsuredPreferredCommunication","Field":"Custom6Code"},{"Alias":"LossEvent_Jurisdiction","Field":"Custom7Code"},{"Alias":"LossEvent_ClaimantSuffix","Field":"CustomText30"},{"Alias":"LossEvent_ClaimantCellPhone","Field":"CustomText31"},{"Alias":"LossEvent_ClaimantAllowText","Field":"CustomBool5"},{"Alias":"LossEvent_ClaimantWorkPhone","Field":"CustomText32"},{"Alias":"LossEvent_ClaimantMiddleName","Field":"CustomText33"},{"Alias":"LossEvent_SocialSecurity","Field":"CustomText34"},{"Alias":"LossEvent_BirthDate","Field":"CustomDate6"},{"Alias":"LossEvent_ClaimantAge","Field":"CustomNumber4"},{"Alias":"LossEvent_Gender","Field":"Custom8Code"},{"Alias":"LossEvent_MaritalStatus","Field":"Custom9Code"},{"Alias":"LossEvent_NumberOfDependents","Field":"CustomNumber5"},{"Alias":"LossEvent_HireDate","Field":"CustomDate7"},{"Alias":"LossEvent_StateOfHire","Field":"Custom10Code"},{"Alias":"LossEvent_Occupation","Field":"CustomText35"},{"Alias":"LossEvent_EmploymentStatus","Field":"Custom11Code"},{"Alias":"LossEvent_WageRate","Field":"CustomMoney1"},{"Alias":"LossEvent_WageRateType","Field":"Custom12Code"},{"Alias":"LossEvent_FullPayOnDayOfInjury","Field":"CustomBool6"},{"Alias":"LossEvent_SalaryContinuedIndicator","Field":"CustomBool7"},{"Alias":"LossEvent_IsThereAnInjuredPartyRelatedToClaim","Field":"CustomBool8"},{"Alias":"LossEvent_ClaimantRepresented","Field":"CustomBool9"},{"Alias":"LossEvent_LossTime","Field":"CustomNumber6"},{"Alias":"LossEvent_TimeBeganWork","Field":"CustomNumber7"},{"Alias":"LossEvent_DateKnownByEmployer","Field":"CustomDate8"},{"Alias":"LossEvent_LastWorkedDate","Field":"CustomDate9"},{"Alias":"LossEvent_DisabilityDate","Field":"CustomDate10"},{"Alias":"LossEvent_DateReturnedToWork","Field":"CustomDate11"},{"Alias":"LossEvent_IsLightDutyWorkAvailable","Field":"CustomBool10"},{"Alias":"LossEvent_WereSafetyMeasuresFollowed","Field":"CustomBool11"},{"Alias":"LossEvent_DeathResultOfInjury","Field":"Custom13Code"},{"Alias":"LossEvent_DeathDate","Field":"CustomDate12"},{"Alias":"LossEvent_PoliceContacted","Field":"CustomBool12"},{"Alias":"LossEvent_ActivityDuringAccident","Field":"CustomNarrative4"},{"Alias":"LossEvent_InjuryInPremises","Field":"Custom14Code"},{"Alias":"LossEvent_AccidentSiteOrganizationName","Field":"CustomText37"},{"Alias":"LossEvent_ObjectCausingInjury","Field":"CustomNarrative5"},{"Alias":"LossEvent_Cause","Field":"Custom15Code"},{"Alias":"LossEvent_Nature","Field":"Custom16Code"}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</form>Text Content
New Claim Record * Check for Duplicates * Save Changes * Cancel WORKERS COMPENSATION - FIRST REPORT OF INJURY * Policy Number: * Intake Code: * Loss Event Type: * Jurisdiction: - None Selected - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Armed Forces Europe, Middle East, & Canada Armed Forces Pacific Canada - Alberta Canada - British Columbia Canada - Manitoba Canada - New Brunswick Canada - Northwest Territories Canada - Newfoundland Canada - Nova Scotia Canada - Nunavut Canada - Ontario Canada - Prince Edward Island Canada - Quebec Canada - Saskatchewan Canada - Yukon Territory District of Columbia Federal Jurisdiction Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico Unknown or Unspecified Virgin Islands * Entered From ACL? INSURED INFORMATION * Employer: * Employer Street 1: * Employer Street 2: * Employer City: * Employer State: - None Selected - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Armed Forces Europe, Middle East, & Canada Armed Forces Pacific Canada - Alberta Canada - British Columbia Canada - Manitoba Canada - New Brunswick Canada - Northwest Territories Canada - Newfoundland Canada - Nova Scotia Canada - Nunavut Canada - Ontario Canada - Prince Edward Island Canada - Quebec Canada - Saskatchewan Canada - Yukon Territory District of Columbia Federal Jurisdiction Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico Unknown or Unspecified Virgin Islands * Employer Postal Code: * Employer Contact Name: * Employer Telephone: ext Enter digits for 'US' or type + for international numbers. * Employer Email: * Employer Email Verify: * Employer Preferred Communication: - None Selected - Email Phone EMPLOYEE/WAGE INFORMATION * First Name: * Middle Name: * Last Name: * Name: * Suffix: * Address Line 1: * Address Line 2: * City: * State: - None Selected - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Armed Forces Europe, Middle East, & Canada Armed Forces Pacific Canada - Alberta Canada - British Columbia Canada - Manitoba Canada - New Brunswick Canada - Newfoundland Canada - Northwest Territories Canada - Nova Scotia Canada - Nunavut Canada - Ontario Canada - Prince Edward Island Canada - Quebec Canada - Saskatchewan Canada - Yukon Territory District of Columbia Federal Jurisdiction Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico Unknown or Unspecified Virgin Islands * Zip: * Home Phone: ext Enter digits for 'US' or type + for international numbers. * Cell Phone: ext Enter digits for 'US' or type + for international numbers. * Allow Text?- None Selected - Yes No * Work Phone: ext Enter digits for 'US' or type + for international numbers. * E-Mail Address: * Employee Email Verify: * E-Mail Address Verify: * SSN: * Date of Birth: * Age: * Sex:- None Selected - Female Male Non-Binary Unspecified * Marital Status:- None Selected - Common Law Divorced Domestic Partnership Married Separated Single Unknown Widowed * Dependents: * Date of Hire: * State of Hire:- None Selected - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Armed Forces Europe, Middle East, & Canada Armed Forces Pacific Canada - Alberta Canada - British Columbia Canada - Manitoba Canada - New Brunswick Canada - Northwest Territories Canada - Newfoundland Canada - Nova Scotia Canada - Nunavut Canada - Ontario Canada - Prince Edward Island Canada - Quebec Canada - Saskatchewan Canada - Yukon Territory District of Columbia Federal Jurisdiction Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico Unknown or Unspecified Virgin Islands * Occupation: * Employment Status:- None Selected - Apprenticeship Full-time Apprenticeship Part-time Disabled Non-Benefited Employee On Strike Other Part-time Employee Piece Worker Regular/Full-time Employee Retired Seasonal Worker Unemployed/Not Employed Volunteer * Rate of Pay: * Per:- None Selected - Annually BiWeekly Daily Hourly Monthly Semi-Monthly Weekly * Days Worked Per Week: Sun Mon Tue Wed Thu Fri Sat * Paid in full for date of injury:- None Selected - Yes No * Did Salary Continue:- None Selected - Yes No INJURY/OCCURRENCE INFORMATION * Is there an injured party related to this claim?- None Selected - Yes No * Is there an attorney representative related to this claim?- None Selected - Yes No * Date of Injury: * Time of Injury: * Report Date: * Time Employee Began Work: * Date Employer Notified: * Last Worked Date: * Date Disability Began: * Date Returned to Work: * Is Light Duty Work Available: - None Selected - Yes No * Were safety measures followed?- None Selected - Yes No * Death Result of Injury: - None Selected - No Unknown Yes * Date of Death: * Cause of Injury:- None Selected - Burn - Chemical Burn - Cold Objects or Substances Burn - Contact NOC Burn - Fire or Flame Burn - Hot Objects or Substances Burn - Steam or Hot Fluids Burn - Temperature Extremes Burn - Welding Operation Caught In, Under, or Between - Machine or Machinery Caught In, Under, or Between - Object Handled Caught In, Under, or Between Collapsing Materials Caught In, Under, or Between NOC Cumulative, NOC Cut, Puncture, or Scrape - Broken Glass Cut, Puncture, or Scrape - Hand Tool Cut, Puncture, or Scrape - Object Being Handled Cut, Puncture, or Scrape - Powered Hand Tool Cut, Puncture, or Scrape NOC Electrical Contact Exposure - Abnormal Air Pressure Fall, Slip, or Trip - Different Level Fall, Slip, or Trip - Ice or Snow Fall, Slip, or Trip - Into Openings Fall, Slip, or Trip - Ladder or Scaffolding Fall, Slip, or Trip - Liquid or Grease Fall, Slip, or Trip - On Same Level Fall, Slip, or Trip - On Stairs Fall, Slip, or Trip NOC Foreign Matter in Eye(s) Gunshot Inhalation of Dust, Gases, Fumes or Vapors Mold or Mildew Motor Vehicle - Collision or Sideswipe with Another Vehicle Motor Vehicle - Collision with a Fixed Object Motor Vehicle - Crash of Airplane Motor Vehicle - Crash of Rail Vehicle Motor Vehicle - Crash of Water Vehicle Motor Vehicle - Vehicle Upset Motor Vehicle NOC Natural Disasters Not otherwise classified in any other code. Applies only to non-impact cases in which the injury resulted from inhalation, absorption (skin contact), ingestion of harmful substances, or vaccinations Other than Physical Cause of Injury Other, Miscellaneous NOC Pandemic Person in Act of Crime Radiation Rubbed or Abraded By - Repetitive Motion Rubbed or Abraded By NOC Slip or Trip, Did Not Fall Stepping on Sharp Object Strain or Injury By - Continual Noise Strain or Injury By - Holding or Carrying Strain or Injury By - Jumping or Leaping Strain or Injury By - Lifting Strain or Injury By - Pushing or Pulling Strain or Injury By - Reaching Strain or Injury By - Repetitive Motion Strain or Injury By - Twisting Strain or Injury By - Using Tool or Machinery Strain or Injury By - Welding or Throwing Strain Or Injury By NOC Striking Against or Stepping On - Moving Part of Machine Striking Against or Stepping On - Object Being Lifted or Handled Striking Against or Stepping On - Sanding, Scraping, Cleaning Operation Striking Against or Stepping On - Stationary Object Striking Against or Stepping On NOC Struck or Injured By - Animal or Insect Struck or Injured By - Explosion or Flare Back Struck or Injured By - Falling or Flying Object Struck or Injured By - Fellow Worker, Patient, or Other Person Struck or Injured By - Hand Tool in Use Struck or Injured By - Motor Vehicle Struck or Injured By - Moving Parts of Machine Struck or Injured By - Object Being Handled by Others Struck or Injured By - Object Being Lifted or Handled Struck or Injured By NOC Terrorism * Nature of Injury:- None Selected - Adverse reaction to a vaccination or inoculation AIDS All Other Cumulative Injury, NOC All Other Occupational Disease Injury, NOC All Other Specific Injuries, NOC Amputation Angina Pectoris Asbestosis Asphyxiation Black Lung Burn Byssinosis Cancer Carpal Tunnel Syndrome Concussion Contagious Disease Contusion COVID-19 Crushing Dermatitis Dislocation Dust Disease, NOC Electric Shock Enucleation Foreign Body Fracture Freezing Hearing Loss or Impairment Heat Prostration Hepatitis C Hernia Infection Inflammation Laceration Loss of Hearing Mental Disorder Mental Stress Multiple Injuries Including Both Physical and Psychological Multiple Physical Injuries Only Myocardial Infarction No Physical Injury Poisoning - Chemical (other than metals) Poisoning - General (Not OD or Cumulative Injury) Poisoning - Metals Puncture Radiation Respiratory Disorders Rupture Severance Silicosis Sprain or Tear Strain or Tear Syncope Vascular VDT - Related Diseases Vision Loss * Body Part(s)- None Selected - Abdomen Including Groin Ankle Artificial Appliance Blindness in both eyes Body Systems and Multiple Body Systems Brain Buttocks Chest - includes ribs, sternum, soft tissue Disc-Back Disc-Neck Ear(s) Elbow Eye(s) Facial Bones-includes jaw Finger(s) Foot Great Toe Hand Head - Soft Tissue - includes face, cheek, forehead, scalp Heart Hip Insufficient Info to Properly Identify - Unclassified Internal Organs Knee Larynx Little toe at distal joint Little toe metatarsal bone Loss of great toe and metacarpal bone thereof Loss of great toe at proximal joint Loss of great toe at second or distal joint Loss of index finger and metacarpal bone thereof Loss of index finger at distal joint Loss of index finger at proximal joint Loss of index finger at second joint Loss of little finger and metacarpal bone thereof Loss of little finger at distal joint Loss of little finger at proximal joint Loss of little finger at second joint Loss of middle finger and metacarpal bone thereof Loss of middle finger at distal joint Loss of middle finger at proximal joint Loss of middle finger at second joint Loss of ring finger and metacarpal bone thereof Loss of ring finger at distal joint Loss of ring finger at proximal joint Loss of ring finger at second joint Loss of thumb and metacarpal bone thereof Loss of thumb at proximal joint Loss of thumb at second or distal joint Lower Arm Lower Back Area Lower Leg Lumbar & or Sacral Vertebrae Lungs Mouth-includes lips, tongue Multiple Body Parts (Including Body Systems and Body Parts) Multiple Head Injury Multiple Lower Extremities Multiple Neck Injury Multiple Trunk Multiple Upper Extremities Neck - Soft Tissue Neck - Spinal Cord No Physical Injury Nose Pelvis Sacrum and Coccyx Shoulder(s) Skull Teeth The loss of any other toe at the distal joint The loss of any other toe at the middle joint The loss of any other toe at the proximal joint The loss of any other toe at the second joint The loss of any other toe with the metatarsal bone thereof The loss of eye by enucleation (including disfigurement resulting there from) Thumb Toes Total blindness of one eye Total Deafness of Both Ears Total Deafness of One Ear Total deafness of one ear after other ear deaf prior to injury Trachea Trunk - Spinal Cord Upper Arm Upper Back Area Upper Leg Vertebrae-Neck Whole Body Wrist Wrist(s) and Hand(s) * Injury Type or Location: - None Selected - Minor - No Injuries, Report Only Minor - Laceration, Puncture, Abrasion Minor - Needle Stick, Bite Wound, Eye Injury Minor - Irritations, Rashes, 1st Degree Burns Minor - Strain, Sprain, Contusion Minor - Unspecified Injury, All Other Moderate - Fracture, Dislocation, Tear Moderate - Repetitive Motion, Carpal Tunnel Moderate - Hernia, Groin, or Abdominal Injury Moderate - Covid-19, Respiratory, Syncope Moderate - 2nd Degree Burns Moderate - Multiple Injuries, All Other Severe - Concussion, Closed Head Injury Severe - Traumatic Brain Injury Severe - Spinal Injury, Disc Herniation Severe - Amputation Severe - Catastrophic, or Fatal Injuries Severe - 3rd Degree Burns Severe - Trauma or ICU, All Other * Police/Fire Contacted?- None Selected - Yes No * Activity During Accident: * Event Description: * Loss Description: * Did injury, illness, or exposure occur on employer’s premises?- None Selected - Yes No * Accident Site Organization Name: * Location Accident Occurred: * Accident Street1: * Accident Street2: * Accident City: * Accident County: * Accident State: - None Selected - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Armed Forces Europe, Middle East, & Canada Armed Forces Pacific Canada - Alberta Canada - British Columbia Canada - Manitoba Canada - New Brunswick Canada - Newfoundland Canada - Northwest Territories Canada - Nova Scotia Canada - Nunavut Canada - Ontario Canada - Prince Edward Island Canada - Quebec Canada - Saskatchewan Canada - Yukon Territory District of Columbia Federal Jurisdiction Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico Unknown or Unspecified USL&H Virgin Islands * Accident Postal Code: * Accident Country: - None Selected - Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua & Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahama Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Darussalam Bulgaria Burkina Faso Burma (no longer exists) Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire (Ivory Coast) Croatia Cuba Cyprus Czech Republic Czechoslovakia (no longer exists) Democratic Yemen (no longer exists) Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France France, Metropolitan French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia German Democratic Republic (no longer exists) Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard & McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iraq Ireland Islamic Republic of Iran Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova, Republic of Monaco Mongolia Monserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles Neutral Zone (no longer exists) New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Romania RTunion Russian Federation Rwanda Saint Lucia Samoa San Marino Sao Tome & Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka St. Helena St. Kitts and Nevis St. Pierre & Miquelon St. Vincent & the Grenadines Sudan Suriname Svalbard & Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Togo Tokelau Tonga Trinidad & Tobago Tunisia Turkey Turkmenistan Turks & Caicos Islands Tuvalu Uganda Ukraine Union of Soviet Socialist Republics (no longer exists) United Arab Emirates United Kingdom (Great Britain) United States Minor Outlying Islands United States of America United States Virgin Islands Unknown or unspecified country Uruguay Uzbekistan Vanuatu Vatican City State (Holy See) Venezuela Viet Nam Wallis & Futuna Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe * Equipment, Materials, or Chemicals Used: TREATMENT INFORMATION * Initial Treatment Code: - None Selected - Trauma/ICU Hospitalized ER Visit Urgent Care Visit Minor Medical No Treatment * Urgent Care or Hospital Name: * Hospital Address: * Hospital City: * Hospital State: - None Selected - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Armed Forces Europe, Middle East, & Canada Armed Forces Pacific Canada - Alberta Canada - British Columbia Canada - Manitoba Canada - New Brunswick Canada - Northwest Territories Canada - Newfoundland Canada - Nova Scotia Canada - Nunavut Canada - Ontario Canada - Prince Edward Island Canada - Quebec Canada - Saskatchewan Canada - Yukon Territory District of Columbia Federal Jurisdiction Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico Unknown or Unspecified Virgin Islands * Hospital Postal Code: * Hospital Telephone: ext Enter digits for 'US' or type + for international numbers. * Treating Physician Name: * Name of Practice: * Physician Address: * Physician City: * Physician State: - None Selected - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Armed Forces Europe, Middle East, & Canada Armed Forces Pacific Canada - Alberta Canada - British Columbia Canada - Manitoba Canada - New Brunswick Canada - Northwest Territories Canada - Newfoundland Canada - Nova Scotia Canada - Nunavut Canada - Ontario Canada - Prince Edward Island Canada - Quebec Canada - Saskatchewan Canada - Yukon Territory District of Columbia Federal Jurisdiction Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico Unknown or Unspecified Virgin Islands * Physician Postal Code: * Physician Telephone: ext Enter digits for 'US' or type + for international numbers. OTHER INFORMATION * Claim being reported by: * Company: * Title: * Telephone Number: ext Enter digits for 'US' or type + for international numbers. * Email Address: * Email Address Verify: * Contact Same as Reporter: - None Selected - Yes No * Contact Name: * Contact Email: * Contact Email Verify: * Contact Phone: ext Enter digits for 'US' or type + for international numbers. * Were there any witnesses?- None Selected - Yes No * Witness: * Telephone Number: ext Enter digits for 'US' or type + for international numbers. Close Ok Close Cancel Close * Minimized -