File a Workers Comp Claim

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1 Employer info
2 Worker Info
3 Accident Info
4 Accident Details
Workers' Compensation Claim
Employer Information | Page 1 of 4
NameEmployer's Legal Name
FEIN
Street Address
AddressLine 2 (optional)
City
ZIP
Nature of Business
Policy Number
Injured Worker Information | Page 2 of 4
Employee Namefull name
Phone
Street Address
AddressLine 2 (optional)
City
ZIP
Worker's ID Number
SSN
Occupationat time of injury
Birthdatemm/dd/yyyy
Gender
Time and Place of Accident | Page 3 of 4
Location Where Accident Occurred
0 /
Date of Injurymm/dd/yyy
Time of Injury
Date Reportedmm/dd/yyy
Was the Injury Fatal
Date of Deathmm/dd/yyy
Number of Dependent Children
Marital Status
Nature and Cause of Accident | Page 4 of 4
Machine, Tool, or Object Causing Injury
Describe How Injury or Illness Occurred
0 /
Describe Nature of Injury or Illnessincluding body parts affected
0 /
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