WORKERS' COMPENSATION CLAIM FORM

(Employee Report of Work-Related Injury or Illness)

TABLE OF CONTENTS

1. Document Header
2. Employee Information
3. Employer Information
4. Injury/Illness Details
5. Medical Treatment Information
6. Witness Information
7. Employee Certification
8. Important Deadlines Reference
9. Employee Rights Notice
10. Submission Instructions

SECTION 1: DOCUMENT HEADER

CLAIM NUMBER: [CLAIM NUMBER - Assigned by Insurer]

DATE OF REPORT: [DATE]

TYPE OF CLAIM:
☐ New Claim
☐ Reopened Claim
☐ Amended Claim

SECTION 2: EMPLOYEE INFORMATION

Full Legal Name: [EMPLOYEE FULL NAME]

Social Security Number (Last 4): XXX-XX-[LAST 4 DIGITS]

Date of Birth: [DOB]

Home Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

Primary Phone: [PHONE NUMBER]

Email Address: [EMAIL]

Gender: ☐ Male ☐ Female ☐ Non-Binary ☐ Prefer Not to Say

Marital Status: ☐ Single ☐ Married ☐ Domestic Partner ☐ Other

Number of Dependents: [NUMBER]

Primary Language: [LANGUAGE]
☐ Interpreter Needed

SECTION 3: EMPLOYER INFORMATION

Employer Legal Name: [EMPLOYER NAME]

Doing Business As (DBA): [DBA IF APPLICABLE]

Employer Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

Employer Phone: [PHONE NUMBER]

Workers' Compensation Insurance Carrier: [INSURANCE CARRIER NAME]

Policy Number: [POLICY NUMBER]

Employee's Job Title: [JOB TITLE]

Department: [DEPARTMENT]

Hire Date: [DATE]

Employment Status:
☐ Full-Time ☐ Part-Time ☐ Seasonal ☐ Temporary

Supervisor Name: [SUPERVISOR NAME]

Supervisor Phone: [PHONE NUMBER]

SECTION 4: INJURY/ILLNESS DETAILS

4.1 Date and Time of Injury/Illness

Date of Injury/Illness: [DATE]

Time of Injury/Illness: [TIME] ☐ AM ☐ PM

Date Reported to Employer: [DATE]

Reported To: [NAME AND TITLE]

Method of Report: ☐ Verbal ☐ Written ☐ Email ☐ Other: [SPECIFY]

4.2 Location of Incident

Did Injury Occur on Employer's Premises? ☐ Yes ☐ No

Specific Location:
[STREET ADDRESS OR LOCATION DESCRIPTION]
[CITY], [STATE] [ZIP CODE]

Location Details (building, floor, room, area):
[DETAILED LOCATION DESCRIPTION]

4.3 Nature of Injury/Illness

Type of Injury/Illness (check all that apply):
☐ Fracture/Broken Bone
☐ Sprain/Strain
☐ Cut/Laceration
☐ Burn
☐ Bruise/Contusion
☐ Amputation
☐ Crushing Injury
☐ Repetitive Strain/Motion Injury
☐ Back Injury
☐ Head Injury/Concussion
☐ Occupational Disease
☐ Respiratory Condition
☐ Hearing Loss
☐ Vision Loss/Eye Injury
☐ Chemical Exposure
☐ Psychological/Mental Stress
☐ Other: [SPECIFY]

Body Parts Affected (check all that apply):
☐ Head ☐ Neck ☐ Face ☐ Eye(s) ☐ Ear(s)
☐ Shoulder (☐ Left ☐ Right ☐ Both)
☐ Upper Arm (☐ Left ☐ Right ☐ Both)
☐ Elbow (☐ Left ☐ Right ☐ Both)
☐ Lower Arm (☐ Left ☐ Right ☐ Both)
☐ Wrist (☐ Left ☐ Right ☐ Both)
☐ Hand (☐ Left ☐ Right ☐ Both)
☐ Finger(s): [SPECIFY WHICH]
☐ Upper Back ☐ Lower Back ☐ Chest
☐ Hip (☐ Left ☐ Right ☐ Both)
☐ Upper Leg (☐ Left ☐ Right ☐ Both)
☐ Knee (☐ Left ☐ Right ☐ Both)
☐ Lower Leg (☐ Left ☐ Right ☐ Both)
☐ Ankle (☐ Left ☐ Right ☐ Both)
☐ Foot (☐ Left ☐ Right ☐ Both)
☐ Toe(s): [SPECIFY WHICH]
☐ Internal Organs: [SPECIFY]
☐ Multiple Body Parts
☐ Other: [SPECIFY]

4.4 Description of Incident

Describe in detail how the injury/illness occurred:

[DETAILED NARRATIVE DESCRIPTION]

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

4.5 Cause of Injury

What Caused the Injury/Illness (check all that apply)?
☐ Slip/Trip/Fall
☐ Struck By Object
☐ Struck Against Object
☐ Caught In/Between Objects
☐ Lifting/Overexertion
☐ Repetitive Motion
☐ Motor Vehicle Accident
☐ Exposure to Harmful Substance
☐ Exposure to Extreme Temperature
☐ Electrical Contact
☐ Machinery/Equipment
☐ Violence/Assault
☐ Animal/Insect
☐ Other: [SPECIFY]

Equipment, Tools, or Substances Involved:
[LIST ALL EQUIPMENT, TOOLS, CHEMICALS, OR OTHER ITEMS]

4.6 Work Activity at Time of Injury

What work activity was being performed?
[DESCRIBE SPECIFIC TASK OR ACTIVITY]

Was this activity part of regular job duties? ☐ Yes ☐ No

If No, explain:
[EXPLANATION]

SECTION 5: MEDICAL TREATMENT INFORMATION

5.1 Initial Medical Treatment

Was Medical Treatment Received? ☐ Yes ☐ No

Date of First Treatment: [DATE]

Type of Initial Treatment:
☐ First Aid Only (on-site)
☐ Emergency Room
☐ Urgent Care
☐ Doctor's Office
☐ Hospital Admission
☐ No Treatment Sought

5.2 Medical Provider Information

Primary Treating Physician:

Name: [PHYSICIAN NAME]
Facility: [FACILITY NAME]
Address: [ADDRESS]
Phone: [PHONE NUMBER]
Fax: [FAX NUMBER]

Hospital/Emergency Room (if applicable):

Name: [FACILITY NAME]
Address: [ADDRESS]
Date(s) of Treatment: [DATES]

5.3 Current Medical Status

Has Employee Returned to Work? ☐ Yes ☐ No

If Yes:
Date Returned: [DATE]
☐ Full Duty ☐ Modified/Light Duty

If No:
Expected Return Date (if known): [DATE]
☐ Unknown at This Time

Is Employee Currently Receiving Medical Treatment? ☐ Yes ☐ No

Describe Current Treatment Plan:
[DESCRIPTION OF ONGOING TREATMENT]

SECTION 6: WITNESS INFORMATION

Were There Witnesses to the Injury/Incident? ☐ Yes ☐ No

Witness 1:

Name: [WITNESS NAME]
Job Title: [TITLE]
Phone: [PHONE NUMBER]
Email: [EMAIL]
Relationship to Employee: ☐ Co-worker ☐ Supervisor ☐ Customer ☐ Other: [SPECIFY]

Witness 2:

Name: [WITNESS NAME]
Job Title: [TITLE]
Phone: [PHONE NUMBER]
Email: [EMAIL]
Relationship to Employee: ☐ Co-worker ☐ Supervisor ☐ Customer ☐ Other: [SPECIFY]

Witness 3:

Name: [WITNESS NAME]
Job Title: [TITLE]
Phone: [PHONE NUMBER]
Email: [EMAIL]
Relationship to Employee: ☐ Co-worker ☐ Supervisor ☐ Customer ☐ Other: [SPECIFY]

SECTION 7: EMPLOYEE CERTIFICATION

I, [EMPLOYEE NAME], hereby certify under penalty of perjury that:

☐ The information provided in this claim form is true, accurate, and complete to the best of my knowledge.

☐ I understand that making a false or fraudulent workers' compensation claim is a crime punishable by imprisonment and/or fine.

☐ I authorize the release of relevant medical records to my employer, the workers' compensation insurance carrier, and their representatives for purposes of evaluating and processing this claim.

☐ I understand that I have the right to consult with an attorney regarding my workers' compensation claim.

☐ I have received a copy of this completed claim form.

Employee Signature: _________________________________

Date: [DATE]

SECTION 8: IMPORTANT DEADLINES REFERENCE

Employee Reporting Deadlines (Examples):

YOUR STATE DEADLINE: [INSERT APPLICABLE STATE DEADLINE]

CRITICAL: Failure to report within required deadlines may result in denial of benefits.

SECTION 9: EMPLOYEE RIGHTS NOTICE

Your Rights Under Workers' Compensation Law:

☐ Right to Medical Treatment: You have the right to receive all medical treatment reasonably required to cure or relieve the effects of your work injury.

☐ Right to Temporary Disability Benefits: If you are unable to work due to your injury, you may be entitled to wage replacement benefits (typically 2/3 of average weekly wage, subject to state maximums).

☐ Right to Permanent Disability Benefits: If your injury results in permanent impairment, you may be entitled to additional benefits.

☐ Right to Vocational Rehabilitation: If you cannot return to your previous job, you may be entitled to retraining benefits.

☐ Right to Legal Representation: You have the right to hire an attorney to represent you in your claim.

☐ Right to Appeal: If your claim is denied, you have the right to appeal the decision.

☐ Protection from Retaliation: It is illegal for your employer to fire, demote, or discriminate against you for filing a workers' compensation claim.

Contact Information for State Workers' Compensation Agency:

Agency Name: [STATE WORKERS' COMPENSATION BOARD/COMMISSION]

Address: [ADDRESS]

Phone: [PHONE NUMBER]

Website: [WEBSITE URL]

SECTION 10: SUBMISSION INSTRUCTIONS

Submit This Form To:

Employer Representative:
Name: [NAME]
Title: [TITLE]
Address: [ADDRESS]
Email: [EMAIL]
Fax: [FAX NUMBER]

AND/OR

Workers' Compensation Insurance Carrier:
Name: [INSURANCE CARRIER NAME]
Claims Department
Address: [ADDRESS]
Phone: [PHONE NUMBER]
Fax: [FAX NUMBER]

Required Attachments:

☐ Copy of medical records/reports (if available)
☐ Witness statements (if available)
☐ Photographs of injury or incident scene (if available)
☐ Other relevant documentation: [SPECIFY]

FOR EMPLOYER USE ONLY

Date Received: [DATE]

Received By: [NAME AND TITLE]

Claim Forwarded to Insurance Carrier: ☐ Yes ☐ No

Date Forwarded: [DATE]

State FROI Filed: ☐ Yes ☐ No

Date FROI Filed: [DATE]

OSHA Recordable: ☐ Yes ☐ No

Employer Notes:
[NOTES]

[END OF DOCUMENT]