Please fill out the form below, upload any pertinent files and click submit. Majority of the fields are required.


Attach doctor’s note, release or other supporting documentation (permits, witness statements, doctors release, photos, etc.)

Maximum size of each file is 5 MB.

Cal/OSHA Accident Reporting Requirements: Employers must immediately report to Cal/OSHA any work-related death or serious injury or illness. Employers may do so by telephone, 24 hours a day, 7 days a week: Definition of Serious Injury or Illness: MSHA Accident Reporting Requirements: If an accident, injury or illness occurs at or in conjunction with activity at a mine, independent contractors are required to report the circumstances of the incident to MSHA using this form/link.

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