Workers' Compensation Claim Submission Form

Date of Injury / Onset of Illness * +

Time Injury / Illness Occured

Time Employee Began Work

Unable to Work for at least one full day after date of injury?

Date last worked * +

Date returned to work * +

Check this box if still off work

Paid full days wages for date of injury or last day worked?

Yes

No

Salary being continued

Yes

No

Date of employers knowledge notice of injury / illness +

Date employee was provided claim form? +

Injury or Illness Information

Specific injury / illness and part of body affected, medical diagnosis if available, e.g. Second degree burns on right arm, tendonitis on left elbow, lead poisoining

Location where event or exposure occured (Number, Street, City, Zip)

On employers premises?

Yes

No

Other workers injured or ill in this event?

Yes

No

Equipment, materials and chemicals the employee was using when event or exposure occured

Specific activity the employee was performing when event or exposure took place, e.g. welding seams of metal forms, loading boxes onto truck

How injury / illness occured? Describe sequence of events, specify object or exposure which directly produced the injury / illness e.g. workers stepped back to inspect work and slipped on scrap material, as he fell he brushed against fresh weld, and burnt right hand. Use separate sheet if necessary.

Name and address of physician (number, street, city, zip)

Hospitalized as an inpatient overnight? If yes then, name and address of hospital (number, street, city, zip)

Employee treated in emergency room? *

Yes

No

Employee Information

Employee name and Social Security Number

Date of Birth * +

Date of Hire * +

Gender *

Male

Female

Home Address (Number, Street, City, Zip)

Occupation (Regular job title, No initials, abbreviations or numbers)

Employee Usually Works

Hours per day

Days per week

Total weekly hours

Employment Status

Regular Full Time

Part Time

Temporary

Seasonal