We Do Business Your Way!™

Welcome to LONG-LEWIS™ est. 1887!

Accident/Injury Customer Report

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • :

  • Accident Location Information

  • Person Injured Information

  • Witness Information

  • Accepted file types: jpg, tiff, pdf, doc, docx, xls, xlsx, Max. file size: 50 MB.
    If you would like to upload photos and/or supporting documents, please do so above. Acceptable file formats are jpg, tiff, pdf, doc, docx, xls, xlsx.

!!ATTENTION!!  ADDITIONAL ACTION REQUIRED!

In addition to completing and submitting the report form above, there is additional form must be filled out, printed, signed by the witness of injured customer, then given to their supervisor to sign and turn into HR.  Please click the button below to get the form.