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Workers Comp Claim Form
First Name *
Last Name *
Organization
Work Phone *
Email Address *
Date of Loss
Employee Information
Name *
Address *
City *
State *
Zip *
Phone *
SSN (no dashes) *
Date of Birth *
Department
Job Title
Weekly Wage
Accident Information
Location of Accident
Nature of Injury/Illness
Description of Incident
Were safeguards or Safety Equipment Provided
Utilized?
Name of Witness
First-Aid Treatment Administered by:
Describe First-Aid Treatment:
Health Insurer:
Panel Provided
Has the employee returned to work?
Actual/Expected Return Date:
Modified Duty Available:
Supervisor's Name:
Supervisor's Phone
Comments:
Information Required: The following information is required to file appropriate documentation with the Worker's Compensation Commission
Employer Federal Tax ID Number: *
Date Disability Began: *
Were wages paid on the date of injury? *
Date Injury Reported to Employer: *
Person injury reported to: *
How long employed: *
Hours worked per day: *
Days worked per week: *
Wages per hour: *
Earnings: *
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