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Report of Injury or Accident Form

Report of Injury or Accident Form

All workplace injuries for clients covered under the Zurich Master Policy or through a stand-alone policy administered by Infiniti HR must be reported to an Infiniti HR representative immediately, regardless of how insignificant the injury or complaint may be at the time of the incident.

An Infiniti HR representative will coordinate prompt medical triage and facilitate the filing of the claim and manage the ongoing claims administration efforts including return-to-work expectations.

The injury reporting form can be accessed below for immediate filing or you can download the pdf, Infiniti HR Injury Data Form, for a hard copy version. Infinti HR will accept either transmission.

Should you need to determine the location of an approved medical facility, please contact us at 866-552-6360 or use the link to access our medical network via the C.A.R.E. directory online.


Report of Injury or Accident Form



  •   Yes
      No
  •   Yes
      No

  •   Male
      Female
  •   Single
      Married
      Separated
      Divorced
      Widowed
      Unknown

  •   No Medical Treatment
      First Aid Only (Onsite)
      Medical Clinic/ER
      EMS Transport
      Hospitalization
  •   No Medical Restrictions
      Media Restrictions
      Lost Time





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