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File A Workers Compensation Claim

EMPLOYER | INSURED INFORMATION
Who Is Submitting This Claim?
First Last
Mobile Phone
Is It Ok For The Carrier To Text Regarding Your Claim?
Email
Name Of Business
Insurance Carrier
Policy Information
EMPLOYEE INFORMATION
Employee Name
First Last
Date of Birth
MM slash DD slash YYYY
Social Security Number
Date Of Hire
MM slash DD slash YYYY
State Of Hire
State
Employee Address
Street Address City State ZIP Code
Employee Phone
Employee Email
Sex
- Male
- Female
- Unknown
Marital Status
- Unmarried | Single | Divorced
- Married
- Seperated
- Unknown
Number Of Dependents
Occupation | Job Title
Employment Status
- Full Time
- Part Time
- Not Employed
- On Strike
- Disabled
- Retired
- Unknown
- Apprenticeship - Full Time
- Apprenticeship - Part Time
- Volunteer
- Seasonal
- Piece Worker
NCCI Class Code (If Known)
Wage Rate (Example $X Per Hour)
Average Weekly Wages
Number of Days Worked Per Week
Full Pay For Day Of Injury?
- Yes
- No
Did Salary Continue?
- Yes
- No
OCCURRENCE | TREATMENT
Time Employee Began Work

: Hours

Minutes

AM/PM
Date Of Injury | Illness
MM slash DD slash YYYY
Time Of Occurrence (approx)

: Hours

Minutes

AM/PM
Last Work Date
MM slash DD slash YYYY
Date Employer Notified
MM slash DD slash YYYY
Date Disability Began (If Applicable)
MM slash DD slash YYYY

The 1st day on which the claimant originally lost time from work due to the injury/disease
Employer Contact
First Last
Name of the individual at the Employer's Premises to be contacted for additional information
Employer Phone
Type Of Injury

Nature of injury or illness (eg. Lacerations to the forearm)
Part Of Body Affected

Indicate the part of body (eg. right forearm, lower back)
Location Accident | Illness Occurred
Street Address City State ZIP Code
All Equipment, Material Or Chemicals Employee Was Using When Accident Or Illness Exposure Occurred
Specific Activity The Employee Was Engaged In When The Accident Or Illness Exposure Occurred
Describe the specific activity
Work Process The Employee Was Engaged In When Accident Or Illness Exposure Occurred
What was the employee doing?
***How Injury Or Illness / Abnormal Health Condition Occurred. Describe The Sequence Of Events And Include Any Objects Or Substances That Directly Injured The Employee Or made The Employee Ill***
Date Returned To Work (If Applicable)
MM slash DD slash YYYY
If Fatal, Give Date Of Death
MM slash DD slash YYYY
Were Safeguards Or Safety Equipment Provided?
- Yes
- No
Were They Used?
- Yes
- No
Select Who The Injured Party Saw For Treatment
- Physician | Healthcare Provider
- Hospital or Offsite Treatment
- NA
Select All That Apply
Physician | Healthcare Provider Name
Physician | Healthcare Provider Contact Person (If Applicable)
Physician | Healthcare Provider Phone
Hospital | Offsite Treatment Provider Phone
Hospital | Offsite Treatment Facility Name
Hospital | Offsite Treatment Facility Contact Person (If Applicable)
Physician | Healthcare Provider Address
Street Address City State ZIP Code
Hospital | Offsite Treatment Provider Address
Street Address City State ZIP Code
Initial Treatment
- No Medical Treatment
- Minor: By Employer
- Minor: Clinic | Hospital
- Emergency Care
- Overnight Hospitalization
- Future Major Medical / Lost Time Anticipated
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File A Workers Compensation Claim

EMPLOYER | INSURED INFORMATION

EMPLOYEE INFORMATION

OCCURRENCE | TREATMENT