HGI Claims Submission

Claimant Information
Claimant Name * First Last
Claimant Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Claimant Phone * - ### - ### ####
Claimant Email
Claimant SSN
Claimant DOB / MM / DD YYYY
Claimant Gender *
Male Female
Date of Hire * / MM / DD YYYY
Job Title
Department Employed
*
Gross Amount of Wages

Weekly-Bi-weekly-Monthly
Employer Information
Employer Name *
Employer Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Employer Phone * - ### - ### ####
Claim Information
Date of Injury * / MM / DD YYYY
Date Reported * / MM / DD YYYY
Date Returned to Work / MM / DD YYYY
Date Disability Began / MM / DD YYYY
Last Full Date Paid / MM / DD YYYY
Accident Description *
Accident Location
Body Part Injured
Wittnesses

Please include names and contact information
Additional Information
Name of Supervisor First Last
Phone of Supervisor - ### - ### ####
Name of Person Completing Report First Last
Email
Lost Time of Medical Only Claim
Possible Disputed Claim
Yes No
If Occupational Disease, give date of Diagnosis
If Hospitalized, Give Name of Facility and Address
Name of Treating Doctor First Last
Phone of Treating Doctor - ### - ### ####