Any information you provide in your “User Account” information will automatically pre-populate all injury reports. The more information you provide in your “User Account,” the less information you have to enter in for each report. For support or more information, please contact John.Brinkman@careworks.com.
*Who is filling out this form?
Injured Worker Employer Provider TPA Other
First Name
Last Name
Company
E-Mail
Street Address
City
State	ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING
Zip Code
Phone	--
Fax	--
User Name
Password
Confirm Password