Notice of Injury Step 1: General Information Employer Name * State Employee Hired In * AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Date of Accident * Policy Number Employee SSN# * Employee’s Supervisor * Accident Location * Employer Phone * Employer Address * Employer Address Line 1 Line 1 Line 2 Line 2 Employer City Employer City Employer State Employer State Employer Zip Employer Zip Next