Report a Claim

This form is for the collection and reporting of data associated with a work-related, injury, illness or incident.

Clients must complete this entire form and submit either by email (preferred method) or signed paper copy to INFINITI HR within 24 hours of receiving notice of the injury, illness, or incident.

It is INFINITI HR’s expectation that the following protocols be met in the event of injury or illness:

  1. Injury, Illness, or any relevant Incident will be immediately reported to INFINITI HR by submission of this form and any supporting documents.
  2. Medical care, when appropriate, will be authorized and client will assure a designated medical facility is utilized (where allowed by statute).
  3. Client will comply with post-accident requirements (substance abuse screening, investigations, return-to-work efforts, and status updates, etc.).

Step 1

Please download and complete the form below.

Step 2

Please upload your completed form here.

  • Max. file size: 60 MB.
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