Packard Claims Administration

First Report of Injury


Our First Notice Unit is staffed with fully trained and knowledgeable claim support professionals. Our employees have a clear understanding of the importance of immediate new claim input so that timely contact can be established. More importantly, they are trained to gather critical claim information and data, and they are tasked with ensuring that your claim data is entered accurately and without error.

Using predictive modeling techniques, we are able to recognize claims that require immediate escalation to Management, enabling us to take early and appropriate action on each new claim received.

Our clients have the ability to report new claims via e-mail, online, or by telephone. Outstanding client service is our first priority.

We can customize any program's First Report and Intake needs on a client-by-client basis to ensure that we are meeting your needs and that your new claims are given our full attention the moment they are reported to us.

To report an accident, please call: 1-800-966-5562 and ask for our Injury Intake Department or fill out our secure online form below. Download PDF verions of the First Report of Injury here

First Report of Injury Form
Employee Information (* = Required Field)
First Name:*
Middle Name:*
Last Name:*
Employee Address:
City:
State:
Zip:
Phone Number:*
SSN:*
Date of Birth:*
Gender:
Email Address:
Occupation:
Date of Accident:*
Time of Accident:*
Address of Accident:
City of Accident:
State of Accident:
Zip of Accident:
Employee Description of Accident
(include cause of injury):
Injury/Illness That Occurred:
Part of Body Affected:

Employer Information (* = Required Field)
Date First Reported:
Date Employed:
Paid for Date of Injury:
Last Date Employee Worked:
Returned to Work:
If Yes, Give Date:
Will You Continue to Pay Wages
Instead of Workers' Comp?:
If Yes, When is the Last Day Wages
Will be Paid Instead of Workers' Comp?
Date of Death (If Applicable):
Agree With Description of Accident?:
Rate of Pay (Per Week):
Number of Hours (Per Week):
Name of Physician or Hospital:
Hospital/Physician Address:
Hospital/Physician City:
Hospital/Physician State:
Hospital/Physician Zip:
Authorized Employer?:
Reporting Information
Person Reporting Injury?: *
Place of Employment: *
Contact Number: *