WORKERS COMPENSATION ACCIDENT ILLNESS REPORT FORM - northeastern 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Part A, where the injured worker or supervisor must provide essential details such as the employee's name, ID, date of birth, and home address. Ensure all fields are filled accurately.
3. In Part A, describe the accident or illness in detail. If necessary, attach a separate sheet for additional information. Don’t forget to indicate any body parts injured and sign at the bottom.
4. Move to Part B for the supervisor’s statement. Discuss the incident with the injured worker before completing this section. Include details about medical treatment received and any witnesses present.
5. Complete the Medical Records Release Authorization by signing and dating it. This is crucial for processing claims effectively.
6. Once completed, send the form via email to insurance@neu.edu or deliver it to Risk Services within 24 hours post-accident. Keep copies for your records.

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