Rusty Bucket - Liberty - Associate - CMR RISK & SAFETY HEADQUARTERS

Employer instructions:
For serious injuries, call 9-1-1 right away.
For all other injuries, assist in the completion of an injury/incident report, and/or the Employer Info section the First Report of Injury (FROI) below.

Associate Injury Reporting Form

* Indicates required field

Store Number & Name *

Policy Number *

Associate Name *

Manager on Duty *

Associate Address *

Line 1

Line 2

City

State

Zip Code

Country

Associate Date of Birth *

Associate Job Title *

Associate Phone Number *

Date of Injury *

Time of Injury *

Cause of Injury *

Did the associate leave their shift to seek medical treatment? *

Yes No

Submit

You can also report to Sedgwick using the following methods:
Phone: Contact their customer service team at 888-627-7586 (available 24/7).
Fax: Send injury forms to 888-711-9284.

Provide the information at the link below to the associate.

Employee Injury Packet