Incident Report

In an emergency

For serious incidents, call 911.

If you’re an Approach client, activate our safety team by calling 206.812.3850. We’re available 24/7 for crisis response.

All employers must report in-patient hospitalization, death, or probable death of any employee within 8 hours to L&I. To report, call your nearest L&I office at 800-423-7233. Click here to see DOSH reporting requirements

General
Date Accident Occured*
Date Format: MM slash DD slash YYYY
Time

: HH

MM
Name of injured employee*
First Last
Company Name*
Specific Location or Site*
Company Phone Number

Incident Details
How did it occur?
What was the injured party doing?
Describe the injury
What part of the body was injured?
What medical treatment was given?
Date of Medical Treatment
Date Format: MM slash DD slash YYYY
Report Completed By:
Email

We will send a copy of the completed form to this address

Contact Information
Do you need a callback?
Callback Phone Number
Existing Claim Number (If Known)

Exclusively for PITB clients Client Portal

In an emergency

General

Incident Details

Contact Information