Please Complete

In the event of an injury, we are required to report information to the State of Kansas. Please complete the form below within 24 hours of the injury occurring.

Name

First Name

Last Name

Email

Address Where Injury Took Place

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Description

Describe what led to the injury and the results of the injury