Test Page Workers' Comp Claims Date of Report:(Required) MM slash DD slash YYYY Injury Type:(Required) Actual Injury with Medical Attention Report Only with Medical Attention Declined Your Claim Number from Qual_Lynx:(Required)School District:(Required)Description of Accident:(Required)JIF: ACCASBO BCIP GCSSD First and Last Name of Injured Employee:(Required)Email Address of Injured Employee: Home Address of Injured Employee:Date of Birth of Injured Employee: MM slash DD slash YYYY Social Security Number of Injured Person, if Available: (State of NJ Requirement)Date of Injury:(Required) MM slash DD slash YYYY Email Address of Person Reporting:(Required)
