Email, fax, or mail to: EMPLOYER’S REPORT OF INJURY MML Fund Claims 3196 Kraft Avenue S.E. Suite 206 form Grand Rapids MI 49512-2065 Fax: 616-649-1796 Email: OSHA LOG CASE # * * THIS REPORT MUST BE COMPLETED AND SIGNED BY THE EMPLOYER * * EMPLOYEE Full Name Soc Sec No. (First, Middle Initial, Male Female Last) City State Zip Employee Date of Birth Marital Dependents ( ) Telephone Status Employee Date of Department Hire INJURY Date of Time of City + ZIP CODE AM Time employee AM Injury Injury Where Injury PM began work PM Occurred What kind of injury? Body Part Injured (contusion, cut, fracture, sprain, strain, etc.) How did injury What was employee doing just before incident occurred? Did Yes No Employee Die Last Day Date Returned If yes, Worked No Time Lost to Work what date? MEDICAL Was employee treated Was employee hospitalized Case No. from Yes No Yes No in an Emergency overnight as an in-patient? Hospital Log Room? Physician/Clinic Address Telephone ( ) Hospital EMPLOYER Full Business Federal ID# Name (Required by BWC) Mailing Address Location Address of Accident Location (if different from mailing address) Telephone Date Injury Was ( ) Reported to Employer Please return to MEADOWBROOK CLAIMS SERVICE 3196 SE, Suite 206, Grand Rapids, MI 49512-2065
EMPLOYER’S REPORT OF INJURY form Email, fax, or mail to: MML Fund Claims 3196 Kraft Avenue S.E. Suite 206 Grand Rapids MI 49512-2065 Fax: 616-649-1796 Email: OSHA LOG CASE # * * THIS REPORT MUST BE COMPLETED AND SIGNED BY THE EMPLOYER * * EMPLOYEE Full Name (First, Middle Initial, Last) Soc Sec No. Male Female City State Zip Employee Telephone ( ) Date of Birth Marital Status Dependents Employee Department Date of Hire INJURY Date of Injury Time of Injury AM PM Time employee began work AM PM City + ZIP CODE Where Injury Occurred What kind of injury? (contusion, cut, fracture, sprain, strain, etc.) Body Part Injured How did injury What was employee doing just before incident occurred? Did Employee Die Yes No Last Day Worked No Time Lost Date Returned to Work If yes, what date? MEDICAL Was employee treated in an Emergency Room? Yes No Was employee hospitalized overnight as an in-patient? Yes No Case No. from Hospital Log Physician/Clinic Address Telephone ( ) Hospital EMPLOYER Full Business Name Federal ID# (Required by BWC) Mailing Address Location Address of Accident Location (if different from mailing address) Telephone ( ) Date Injury Was Reported to Employer Please return to MEADOWBROOK CLAIMS SERVICE 3196 SE, Suite 206, Grand Rapids, MI 49512-2065