Workers’ Compensation Accident Report Form

Any employee who sustains a job-related injury or illness is to report the incident immediately to the supervisor who files a Supervisor’s Report of Injury Form with Risk Management within 24 hours. Risk Management is responsible for supervising the program, including the initial┬áinvestigation of claims. Processing indemnity checks and medical payments is the┬áresponsibility of PMA under direct supervision of Risk Management. All claims are subject to review by the Workers’ Compensation Board. Please complete the form and forward to Risk Management with original signatures. Instructions are on page 2.