Report a workplace injury

If this is a medical emergency, call 911 first. Then fill out this form as completely as you can so we can file your claim with Montana State Fund. Our office will complete the rest. Your information is sent only to Evolution management.

Your information

Tell us who you are.

First name *

Last name *

Gender *

Date of birth *

Social Security number *

Required by Montana State Fund to file the claim.

Phone number *

Email address *

Mailing address *

City *

State *

ZIP code *

About the accident

What happened, and where.

Date of injury *

Time of injury

Your job title *

Part of body injured *

Describe what happened *

What were you doing, and how did the injury occur?

Witness 1 (name)

Anyone who saw what happened — leave blank if there were no witnesses.

Witness 2 (name)

Where did it happen? (address or job site) *

City

State

Have you missed work because of this injury? *

If yes, the last day you worked

Documents (optional)

Attach photos of the injury or scene, medical paperwork, or anything else that helps. You can add more than one.

This report is timestamped and sent to Evolution management immediately.