Workers Compensation Claim
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Policy
Employer
Claim
Inj Worker
Providers
Witnesses
Finish
Begin Your Claim
Name of Person Reporting Claim
*
First Name
*
Last Name
Address
*
Work Phone
Extension
Cell Phone
Email
Are you a party to the claim?
Yes
No
What is your relationship to the claim?
Employer
Injured Employee
Attorney
Agent
Other
Policyholder
Insurer/Carrier Name
Address
Carrier FEIN
Policy or Self Insured#
Insured Name
Self Insured?
Yes
No
Insured FEIN
Policy Effective Date
Policy Expiration Date
Employer
*
Company Name
Physical Address
*
Work Phone
Extension
Cell Phone
Mailing Address (Leave empty if same as Physical Address)
Employer FEIN
Employer SIC/NAICS Code
Location Code #
Division #
Employer Contact First Name
Employer Contact Last Name
Work Phone
Extension
Cell Phone
Email
Employer Nature of Business
Claim Details
Time Employee Began Work
*
Date of Injury or Illness
Time of Injury or Illness
Last Work Date
Date Employer Notified
Date Disability Began
*
Accident Description
If Fatal, Date of Death
Occurrence on Insured Premises?
Yes
No
Accident Location
City
State
*
Zip
List Equipment, Materials, or Chemicals used by Employee when the incident occurred
Specific Activity the Employee was engaged in when the incident occurred
Work process the Employee was engaged in when incident occurred
Were Safeguards or Safety Equipment provided?
Yes
No
Type of Illness/Injury
Cause of Injury/Illness
Part of Body Affected
Initial Treatment
No Medical Treatment
Emergency Care
Minor Treatment by Employer
Hospitalized/24 hours
Minor Treatment at Clinic/Hospital
Future Major Medical/Lost Time Anticipated
Is this OSHA Reportable?
Yes
No
OSHA log #
Injured Party
*
First Name
*
Last Name
Date of Birth
Social Security #
Date of Hire
Green Card or Employment Visa #
Home Phone
Cell Phone
Home Physical Address
Home Mailing Address (Leave Empty if same as Physical Address
Work Phone
Email
Gender
Male
Female
Marital Status
Single
Married
Separated
Unknown
Occupation/Job Title
Employment Status
Regular/Full-Time
Disabled
Full-Time Apprenticeship
On Strike
Part-Time Apprenticeship
Part Time Employee
Piece Worker
Retired
Seasonal Worker
Unemployed/Not Employed
Volunteer Worker
Other
NCCI Class Code
Wage Rate
Wage Rate Per
Day
Week
Month
Wage Rate Other
Days Worked Per Week
Hours Worked Per Day
Full Pay for Date of Injury
Yes
No
Did Salary Continue?
Yes
No
Medical Providers
Medical Provider #1
Medical Provider Name
Address
Phone
Medical Provider #2
Medical Provider Name
Address
Phone
Medical Provider #3
Medical Provider Name
Address
Phone
Hospital Name
Address
Phone
Witnesses
Witness #1
Address
Contact Phone
Cell Phone
Email
Witness #2
Address
Contact Phone
Cell Phone
Email
Witness #3
Address
Contact Phone
Cell Phone
Email
Summary
Is there anything else that you would like to note?
Attachments
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