Missoula County, MT · Missoula County
Accident/Injury Information Request
Missoula County employees use this form to report accident or injury information and provide details for the county’s benefits and risk review.
At a glance
- Issued by
- City of Missoula County · Missoula County, Missoula County, Montana
- Notarization
- Not required: file this form without a notary.
- Official source
- missoulacounty.gov
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
The Accident/Injury Information Request collects employee and injured-person details, information about the accident and medical treatment, and third-party liability information if someone else may be responsible. Employees complete and sign it to provide information to Missoula County Risk and Benefits. The form says work-related injuries must also be filed with Workers’ Compensation.
Who needs it
A Missoula County employee seeking medical attention for an accident or injury should complete the form and provide the requested information.
How to submit it
Submit it to the county department named on the form; check the county website for current contact details before sending.
About notarization
This form is signed without a notary; the employee and, if 18 or older, the patient sign and date it.
How to submit this form
- 1
Download the Form
Download the Accident/Injury Information Request PDF.
- 2
Complete the Form
Fill in the employee, injured-person, accident, medical-treatment, and applicable third-party liability details.
- 3
Sign and Date
The employee signs and dates the form; the patient also signs and dates it if 18 or older.
- 4
Submit to the County
Submit it to the county department named on the form; check the county website for current contact details.
Frequently asked questions
- What information does the Accident/Injury Information Request ask for?
- It asks for employee and injured-person details, information about the accident and medical treatment, and third-party liability information when someone else may be responsible.
- Do I need a notary for the Accident/Injury Information Request?
- No. The employee signs and dates the form, and the patient also signs and dates it if 18 or older; no notary is indicated.
- How do I submit the Accident/Injury Information Request?
- Submit it to the county department named on the form; check the county website for current contact details before sending.
- What if the injury is work-related?
- The form states that if you mark the injury as work-related, you must file the claim with Workers’ Compensation.