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 Overview    
  Incident Overview  


  Claimant Last Name : Alabama

  FROL_ID Number : 1001554

  Site Code : ZR.DP-54321

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

  Injury :
     Date : 02/06/2003
     Report Number : 2003-1
     Accident State : AL
     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 send the package to the Care Center.
4 Click on Transmit to complete the process and send the transmittal package to the Care Center.
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.
Incident Transmittal Details
 Customer Number
 Contact Name
 Contact Phone
 Contact Email
 Employee's Employment Status
 Employee losing time from work?
 Employee's Weekly Wage
 Employee's Supervisor Name
 Employee's Supervisor Phone
Transmittal Comment (300 characters max)
Report History (click to view or download)