First Report of Injury

Employee Accident With or Without Injury

Worker Injuries

Find a Clinic to treat an Injury

Click here to find closest treating Doctor or Hospital

When you have an injured worker:

In an Emergency Call "911"
Call your supervisor ASAP.
Non-Emergency Related injuries can use the link above to find a clinic to care for the worker.
Call HR Director to inform of the injury: Sarah Johnson 214.642.1501
Manager/Coordinator must go to "Manager's Portal" and complete the information to report the injury....this must be done in 24 hrs of the injury.

First Report of Employee Injury (Claim # will be generated if applicable)

Texas Mutual Doc Find

If needed pease use the Texas Mutual (Doc Find) link above to find the nearest doctor from where you are located that can see a patient for a worker's comp injury.

Please complete this form in it's entirety and we will contact you as soon as possible.

Worksite: (City &State)
Site Address (Street City State Zip) where injury happened:*

Date of Injury:*
Time of Injury:*
Date Injury Reported to Supervisor:

Person Injured First Name:*
Last Name:*
Home Office Location of Injured Employee:

Employee Address:*
City:*
State:
Zip Code:*
Employee Personal Phone:*
Employee Work Phone:*
Date of Birth*
Employee SS#*

Supervisor's Full Name:*
Supervisor's Phone #:*

Employee Hire Date*

Description of Injury (please provide as much details as you can):*
Was the person performing normal job function at time of injury?
Please explain the work that was being performed at the time of injury (Details):*
Was the person wearing PPE?*
What body part was injured?*
Nature of the injury?*
If possible please provide a picture of the injury.

Was an ambulance called?

Who responded to the site? (Fire Dept Name Police Dept Name Ambulance)
Severity of Injury (1 = Minor to 5 = Fatal)

Where is the person now?*
Where was the person taken for treatment (clinic/hospital)? (Address & Phone #)*
Has the person returned to work?
Comment/Notes
Name of Person Submitting Report:*
Do not enter anything in this field:

* indicates a required field

Please fill this field.

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