Incident Transmittal Form
Use this form to create or edit the incident record transmittal coversheet and transmit the incident for processing.
Last Report Generated (click to view or download)
     Incident Summary Information     
  Incident Overview  


  Claimant Last Name : Michigan

  FROL_ID Number : 1001564

  ID Code Description : Employer Code
  ID Code Value : E-12345

  Employer :
     Lorien, Inc.
     9983 Wonderful Way
     Concord NC 12892 3282
     FEIN : 45 9223058

  Injury :
     Date : 03/10/2003
     Report Number : 2003-7
     Accident State : MI
     Occur on premises? : Yes
     Reported by : 
     Nature of injury : Not Defined
     Part of body : Not Defined ()
Incident Description

Incident Transmittal History

This incident has not been previously transmitted.
Incident Transmittal Instructions
1 View the "Incident Overview" above to verify completeness and accuracy.
2 Complete the "Incident Transmittal Details" form fields below. Fields with a red border are required. Keep comments specific to the transmittal process.
3 Click on Report if you want only to create a transmittal package and do not want to transmit the package for processing.
4 Click on Transmit to complete the process and transmit the package for processing.
5 When the process is complete you will return to the incident form. You can then go to "Last Report Generated" to get a copy of the transmittal package.
 Customer Number
 Contact Name
 Contact Phone
 Contact Email
Transmittal Comment (300 characters max)
FAX Information
This incident has been marked for transmittal by fax. The phone number(s) below have been pre-filled from your profile information. You may edit this information if desired. Fax numbers must be 10 digit numbers including the area code.
 Fax Phone Number 1
 Fax Phone Number 2
Report History (click to view or download)