Accident LocationHampton elementary
Districtbay_city
Supervisor NameKaren Allore
Date of Accident04/03/2026
Time of Accident02:44 PM
Employee NameVictor Velasquez
Address801 Howard street
Bay city, MIchigan 48708
Map It
Phone(989) 964-1812
Date of Birth06/17/2004
Last 4 digits of your Social Security Number0207
Do you think you need to see a doctor today?No
Description of Accident
Me and a coworker were picking up kaivac out of the truck bed and the kaivac slipped and landed directly on my knee.
What part of your body has been injured? Check all that apply- Right Leg
- Right Knee
AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.
I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.
All records for any and all dates of evaluation, care or treatment to be disclosed.
Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620
The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.
As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
This authorization expires one year from the date of execution.
A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.
Electronic SignatureVictor velasquez
Date04/03/2026
Accident LocationWarehouse
Districtoffice
Supervisor NameJim Gee
Date of Accident03/31/2026
Time of Accident02:45 PM
Employee NameGordon Stricklen
Address4596 Tabor rd nw
Comstock Park, Mi 49321
Map It
Phone(616) 408-3813
Date of Birth06/27/1976
Last 4 digits of your Social Security Number5494
Do you think you need to see a doctor today?No
Description of Accident
My chair broke fell backwards hit back of my head on the ground...im ok
What part of your body has been injured? Check all that apply- Head
AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.
I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.
All records for any and all dates of evaluation, care or treatment to be disclosed.
Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620
The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.
As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
This authorization expires one year from the date of execution.
A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.
Electronic SignatureGordon Stricklen
Date04/01/2026
Accident LocationWhitman
Districtpontiac
Supervisor NameBrianna Cortez
Date of Accident03/25/2026
Time of Accident08:00 AM
Employee NameTiffany Anderson
Address211 west Kennett rd
Pontiac, MIchigan 48340
Map It
Phone(248) 873-9727
Date of Birth04/25/1994
Last 4 digits of your Social Security Number6733
Do you think you need to see a doctor today?Not Sure
Description of Accident
I was pulling apart and putting together heavy duty wooden tables
What part of your body has been injured? Check all that apply- Upper Back
- Left Shoulder
AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.
I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.
All records for any and all dates of evaluation, care or treatment to be disclosed.
Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620
The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.
As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
This authorization expires one year from the date of execution.
A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.
Electronic SignatureTiffany Anderson
Date03/26/2026
Accident LocationBelding high school
Districtbelding
Supervisor NameAlexis Weaver
Date of Accident03/17/2026
Time of Accident09:20 PM
Employee NameMichael Smalley
Address49 belhaven dr
Belding, MIchigan 48809
Map It
Phone(989) 436-1283
Date of Birth02/06/1987
Last 4 digits of your Social Security Number5166
Do you think you need to see a doctor today?No
Description of Accident
Cut on finger
What part of your body has been injured? Check all that apply- Right Hand
AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.
I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.
All records for any and all dates of evaluation, care or treatment to be disclosed.
Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620
The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.
As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
This authorization expires one year from the date of execution.
A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.
Electronic SignatureMichael Smalley
Date03/17/2026
Accident LocationComstock Park
Districtoffice
Supervisor NameLogan White
Date of Accident03/11/2026
Time of Accident04:40 PM
Employee NameKari Monroe
Address16300 Northland Drnullnull
Sand Lake, MIchigan 49343-9464
Map It
Phone(616) 432-7647
Date of Birth11/19/1986
Last 4 digits of your Social Security Number8171
Do you think you need to see a doctor today?Not Sure
Description of Accident
Got into a head on collision with my car as I was driving to Comstock Park.
What part of your body has been injured? Check all that apply- Head
- Lower Back
- Left Hand
- Left Knee
AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.
I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.
All records for any and all dates of evaluation, care or treatment to be disclosed.
Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620
The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.
As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
This authorization expires one year from the date of execution.
A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.
Electronic SignatureKari Ann Monroe
Date03/12/2026
Accident LocationIonia
Districtionia
Supervisor NameLance Reeves
Date of Accident02/27/2026
Time of Accident04:30 PM
Employee NameTaylor Hill
Address345 Liberty St
muir, MIchigan 48860
Map It
Phone(616) 597-0769
Date of Birth09/15/1999
Last 4 digits of your Social Security Number8397
Do you think you need to see a doctor today?No
Description of Accident
I was moving the mop bucket and bought the cord for the vacuum and dropped in on my head
What part of your body has been injured? Check all that apply- Head
AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.
I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.
All records for any and all dates of evaluation, care or treatment to be disclosed.
Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620
The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.
As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
This authorization expires one year from the date of execution.
A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.
Electronic SignatureTaylor Hill
Date02/27/2026
Accident LocationTest
Districtoffice
Supervisor NameTest Test
Date of Accident02/18/2026
Time of Accident01:22 AM
Employee NameTest Test
AddressMIchigan
Map It
Phone(517) 749-1133
Date of Birth02/09/2026
Last 4 digits of your Social Security Number1111
Do you think you need to see a doctor today?Yes
Description of Accident
Test
What part of your body has been injured? Check all that apply- Upper Back
- Middle Back
AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.
I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.
All records for any and all dates of evaluation, care or treatment to be disclosed.
Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620
The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.
As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
This authorization expires one year from the date of execution.
A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.
Electronic SignatureTesting
Date02/18/2026
Accident LocationDewitt Middle School
Districtdewitt
Supervisor NameBlayne Knechtges
Date of Accident02/18/2026
Time of Accident05:45 PM
Employee NameWilliam Wissner
AddressMIchigan
Map It
Phone(517) 303-3436
Date of Birth03/12/1955
Last 4 digits of your Social Security Number5183
Do you think you need to see a doctor today?Yes
Description of Accident
Accidentally got comet in eye while cleaning toilet.
What part of your body has been injured? Check all that apply- Right Eye
AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.
I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.
All records for any and all dates of evaluation, care or treatment to be disclosed.
Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620
The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.
As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
This authorization expires one year from the date of execution.
A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.
Electronic SignatureWilliam Wissner
Date02/18/2026
Accident LocationTri County Elementary Big Bathroom across from the cafeteria
Districttri_county
Supervisor NameLisa Johnson
Date of Accident02/17/2026
Time of Accident07:30 PM
Employee NameMegan Esakson
Address13612 Cypress Ave
Sand lake, MIchigan 49343
Map It
Phone(616) 350-2630
Date of Birth02/12/1998
Last 4 digits of your Social Security Number6893
Do you think you need to see a doctor today?Yes
Description of Accident
I was using strong on the toilets and when I lifted it up a drop/stream of it flew up from the bottle and into my eye. I yelled for help but no one head me so I called my lead Karmon and she called Lisa. I flushed my eye out with sink water, had Karmon pull sds sheet, and called my fiance for a ride to the hospital
What part of your body has been injured? Check all that apply- Right Eye
AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.
I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.
All records for any and all dates of evaluation, care or treatment to be disclosed.
Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620
The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.
As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
This authorization expires one year from the date of execution.
A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.
Electronic SignatureMegan Esakson
Date02/17/2026
Accident LocationLudington Fifth Third Bank
Districtgrand_rapids_banks
Supervisor NameKarie Sustaita
Date of Accident02/12/2026
Time of Accident09:46 PM
Employee NameGilbert Hatley
Address1105 Lancer Lane
Ludington, MIchigan 49431
Map It
Phone(231) 852-3734
Date of Birth09/17/1971
Last 4 digits of your Social Security Number3780
Do you think you need to see a doctor today?No
Description of Accident
Slipped on ice at the back door of the Fifth Third Bank Ludington Branch. The whole area is all ice
What part of your body has been injured? Check all that apply- Left Hand
AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.
I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.
All records for any and all dates of evaluation, care or treatment to be disclosed.
Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620
The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.
As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
This authorization expires one year from the date of execution.
A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.
Electronic SignatureGilbert Hatley
Date02/12/2026
Accident LocationWayland middle school
Districtgr_route
Supervisor NameLogan White
Date of Accident02/12/2026
Time of Accident06:50 PM
Employee NameJolene Moore
Address950 Denhertog St SW
Wyoming, MIchigan 49509
Map It
Phone(616) 893-7876
Date of Birth09/01/1977
Last 4 digits of your Social Security Number2966
Do you think you need to see a doctor today?No
Description of Accident
Pinch my fingers in the door .
One of hallway door.
I have two cuts.
What part of your body has been injured? Check all that apply- Right Hand
AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.
I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.
All records for any and all dates of evaluation, care or treatment to be disclosed.
Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620
The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.
As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
This authorization expires one year from the date of execution.
A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.
Electronic SignatureJolene Moore
Date02/12/2026
Accident LocationIonia high school gym
Districtionia
Supervisor NameNicole Vincent
Date of Accident02/06/2026
Time of Accident09:30 PM
Employee NameJessica Garvie
Address220 Dunham st
Sunfield, MIchigan 48890
Map It
Phone(616) 902-7087
Date of Birth01/21/1979
Last 4 digits of your Social Security Number2324
Do you think you need to see a doctor today?No
Description of Accident
Wearing vacpack that didn't fit well, straps kept slipping and not able to clip them together
What part of your body has been injured? Check all that apply- Neck
- Right Shoulder
AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.
I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.
All records for any and all dates of evaluation, care or treatment to be disclosed.
Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620
The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.
As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
This authorization expires one year from the date of execution.
A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.
Electronic SignatureJessica Garvie
Accident LocationClassroom
Districtnorthville
Supervisor NameAngela Sisson
Date of Accident02/05/2026
Time of Accident08:00 PM
Employee NameKyle Costie
Address9944 Floros lane
South Lyon, MIchigan 48178
Map It
Phone(906) 250-3029
Date of Birth02/21/1982
Last 4 digits of your Social Security Number3030
Do you think you need to see a doctor today?Yes
Description of Accident
Sharp pain in neck while mopping
What part of your body has been injured? Check all that apply- Neck
AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.
I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.
All records for any and all dates of evaluation, care or treatment to be disclosed.
Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620
The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.
As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
This authorization expires one year from the date of execution.
A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.
Electronic SignatureKyle j costie
Date02/09/2026
Accident LocationClassroom
Districtnorthville
Supervisor NameAngela Sisson
Date of Accident02/05/2026
Time of Accident06:00 PM
Employee NameKyle Costie
Address9944 Floros Ln
South Lyon, MIchigan 48178
Map It
Phone(906) 250-3029
Date of Birth02/21/1982
Last 4 digits of your Social Security Number368043030
Do you think you need to see a doctor today?Not Sure
Description of Accident
From mopping room neck injury occurred causing pain in neck and right arm
What part of your body has been injured? Check all that apply- Neck
- Right Shoulder
- Right Wrist
- Right Hand
AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.
I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.
All records for any and all dates of evaluation, care or treatment to be disclosed.
Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620
The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.
As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
This authorization expires one year from the date of execution.
A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.
Electronic SignatureKyle Costie
Date02/21/1982
Accident LocationTri county high school
Districttri_county
Supervisor NameRyan Menefee
Date of Accident02/05/2026
Time of Accident09:15 AM
Employee NameMelanie Taylor
Address190 E Lake St NE
Sand Lake, MIchigan 49343
Map It
Phone(616) 655-5281
Date of Birth04/20/1978
Last 4 digits of your Social Security Number2354
Do you think you need to see a doctor today?No
Description of Accident
Hit my head
What part of your body has been injured? Check all that apply- Head
AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.
I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.
All records for any and all dates of evaluation, care or treatment to be disclosed.
Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620
The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.
As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
This authorization expires one year from the date of execution.
A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.
Electronic SignatureMelanie Taylor
Date02/05/2026
Accident LocationLakeview middle school
Districtlakeview_bc
Supervisor NameJames Cannon
Date of Accident01/21/2026
Time of Accident05:30 AM
Employee NameAshley Clements
Address3399 capital ave sw
Apt 37b
Battle creek, MIchigan 49015
Map It
Phone(269) 983-5191
Date of Birth12/19/1987
Last 4 digits of your Social Security Number6825
Do you think you need to see a doctor today?No
Description of Accident
I was shoveling like I was suppose to for snow removal, and when I started doing the three foot snow drifts on the fire exit I started to feel pain in my right shoulder do to the snow being heavy and packed. The pain was gradually getting worse up until this week where I went to urgent care last Friday they said I have four muscles pulled in my right shoulder. Gave me meds I came back to work on February fourth I was doing my normal easy stuff and my shoulder was on fire tried to stay during lunch and couldn’t stand the pain left work and had an appt with my family doctor same day they confirmed I pulled my four muscles in my shoulder gave me stronger muscle relaxers and lidocaine patches and a stronger anti inflammatory meds which all seem to be helping so far.
What part of your body has been injured? Check all that apply- Right Shoulder
AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.
I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.
All records for any and all dates of evaluation, care or treatment to be disclosed.
Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620
The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.
As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
This authorization expires one year from the date of execution.
A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.
Electronic SignatureAshley m clements
Date02/05/2026
Accident LocationLakeview High School
Districtlakeview_bc
Supervisor NameConnie Keiser
Date of Accident02/03/2026
Time of Accident10:30 PM
Employee NameAlexander Nowicki
Address9655 E Eddy Road
Bellevue, MIchigan 49021
Map It
Phone(269) 986-5807
Date of Birth02/16/2003
Last 4 digits of your Social Security Number8027
Do you think you need to see a doctor today?Not Sure
Description of Accident
I was cleaning the gym, and accidentally bumped my head on the medal under the bleachers. And I cut my head accidentally and it started bleeding. And today it still is bleeding today a little bit
What part of your body has been injured? Check all that apply- Head
AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.
I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.
All records for any and all dates of evaluation, care or treatment to be disclosed.
Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620
The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.
As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
This authorization expires one year from the date of execution.
A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.
Electronic SignatureAlexander J Nowicki
Date02/04/2026
Accident LocationPortage Amberly elementary
Districtoffice
Supervisor NameBob Cheeseman
Date of Accident01/28/2026
Time of Accident09:30 PM
Employee NameJaquan Mccoy
Address8q4 lane Blvd
Kalamazoo, MIchigan 49001
Map It
Phone(269) 251-7245
Date of Birth10/07/2007
Last 4 digits of your Social Security Number2915
Do you think you need to see a doctor today?Not Sure
Description of Accident
I was restocking my closest after got done my hand start burning
What part of your body has been injured? Check all that apply- Right Hand
AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.
I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.
All records for any and all dates of evaluation, care or treatment to be disclosed.
Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620
The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.
As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
This authorization expires one year from the date of execution.
A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.
Electronic SignatureJaquan mccoy
Date01/28/2026
Accident LocationVicksburg Middle School
Districtvicksburg
Supervisor NameDarlene Case
Date of Accident01/23/2026
Time of Accident04:00 PM
Employee NameBrian Thole
Address14680 Portage Rd
Vicksburg, MIchigan 49097
Map It
Phone(269) 352-1657
Date of Birth03/11/1974
Last 4 digits of your Social Security Number7185
Do you think you need to see a doctor today?Yes
Description of Accident
I was doing snow removal at the the Middle School during that week. Also on Wednesday I lifted heavy recycling tote.
Note there isn't an option to choose below for the body part that's injured. It's on right side of the groin area lump consistent with a hernia
AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.
I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.
All records for any and all dates of evaluation, care or treatment to be disclosed.
Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620
The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.
As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
This authorization expires one year from the date of execution.
A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.
Electronic SignatureBrian Thole
Date01/26/2026
Accident LocationVicksburg Middle school
Districtoffice
Supervisor NameAmber Ransom
Date of Accident01/23/2026
Time of Accident04:00 PM
Employee NameBrian Thole
Address14680 portage rd.
Vicksburg, MIchigan 49097
Map It
Phone(269) 352-1657
Date of Birth03/11/1974
Last 4 digits of your Social Security Number7185
Do you think you need to see a doctor today?Not Sure
Description of Accident
Hes reporting that it either happened on Wednesday January 21 while emptying a tote of recycling or on Friday January 23 while shoveling snow. When he got home around 4pm on Friday January 23 he noticed a pain and a lump in his groin area. He has just reported this to us on Monday January 26
AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.
I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.
All records for any and all dates of evaluation, care or treatment to be disclosed.
Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620
The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.
As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
This authorization expires one year from the date of execution.
A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.
Electronic SignatureAmber Ransom
Date01/26/2026
Accident LocationWoodland Elementary portage
Districtportage
Supervisor NameReymundo Trevino
Date of Accident01/14/2026
Time of Accident05:40 PM
Employee NameYesenia Rivera
Address3426 Comstock Village Kn
Apt 105
Kalamazoo, MIchigan 49048
Map It
Phone(269) 303-7358
Date of Birth02/10/1991
Last 4 digits of your Social Security Number8097
Do you think you need to see a doctor today?No
Description of Accident
Was setting up for a music event and accidentally trip over her foot and landed on her knees and back
What part of your body has been injured? Check all that apply- Lower Back
- Left Knee
- Right Knee
AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.
I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.
All records for any and all dates of evaluation, care or treatment to be disclosed.
Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620
The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.
As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
This authorization expires one year from the date of execution.
A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.
Electronic SignatureReymundo Trevino
Date01/14/2026
Accident LocationSteeby Elementary
Districtwayland
Supervisor NameBrandy Homrich
Date of Accident01/02/2026
Time of Accident11:00 AM
Employee NameMelissa Cawley
Address539 W Superior St
Wayland, MIchigan 49348
Map It
Phone(616) 238-4470
Date of Birth05/08/1981
Last 4 digits of your Social Security Number4091
Do you think you need to see a doctor today?Yes
Description of Accident
Bent finger backwards when trying to solve an issue with a kiavac.
What part of your body has been injured? Check all that apply- Left Hand
AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.
I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.
All records for any and all dates of evaluation, care or treatment to be disclosed.
Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620
The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.
As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
This authorization expires one year from the date of execution.
A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.
Electronic SignatureMelissa Cawley
Date01/07/2026
Accident Location1460 silver springs. Door 32
Districtnorthville
Supervisor NameTammy Stankeiwicz
Date of Accident01/05/2026
Time of Accident05:17 AM
Employee NameWilliam oliver
Address1515 Ridge Rd
Lot 187
Ypsilanti, MIchigan 48198
Map It
Phone(313) 687-2407
Date of Birth03/15/1976
Last 4 digits of your Social Security Number1499
Do you think you need to see a doctor today?Not Sure
Description of Accident
I was doing snow removal and slipped and fell on my back. Now my back hurt
What part of your body has been injured? Check all that apply- Middle Back
- Lower Back
AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.
I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.
All records for any and all dates of evaluation, care or treatment to be disclosed.
Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620
The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.
As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
This authorization expires one year from the date of execution.
A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.
Electronic SignatureWilliam c oliver III
Date01/05/2026
Accident LocationSteeby elem
Districtwayland
Supervisor NameJaiden Mccrea
Date of Accident01/02/2026
Time of Accident10:10 PM
Employee NameDaniel White
Address223 n main
Allegan, MIchigan 49010
Map It
Phone(269) 512-2489
Date of Birth11/17/1968
Last 4 digits of your Social Security Number0568
Do you think you need to see a doctor today?No
Description of Accident
Extension cord caught on fire where it plugs into backpack vacuum. Reached down to unplug and scorched middle finger on left hand
What part of your body has been injured? Check all that apply- Left Hand
AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.
I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.
All records for any and all dates of evaluation, care or treatment to be disclosed.
Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620
The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.
As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
This authorization expires one year from the date of execution.
A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.
Electronic SignatureDaniel White
Date01/02/2026
Accident LocationCadillac mackinaw trail ms
Districtoffice
Supervisor NameJames Gee
Date of Accident01/02/2026
Time of Accident01:20 PM
Employee NameJames Gee
Address3861 rhodes rd
Rhodes, MIchigan 48652
Map It
Phone(989) 621-9329
Date of Birth11/29/1977
Last 4 digits of your Social Security Number0313
Do you think you need to see a doctor today?Not Sure
Description of Accident
Stepped in hole by dumpster. Ankle popped.