Workers' Compensation Interview Form (1)
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1
2WORKERS' COMPENSATION ONLINE INTERVIEW FORM
(Complete Form and Fax to 973-802-1055)
NAME:
ADDRESS:
CITY:
STATE:
ZIP:
COUNTY:
HOME PHONE: ___________________________
CELL PHONE: __________________________
SSN:
SEX: MALE
FEMALE
DOB:
OCCUPATION:
MARITAL STATUS:
NAME/AGES OF CHILDREN:
NAME OF SPOUSE:
AGE:
EMPLOYER:
ADDRESS:
PHONE:
CITY: ______________________________ STATE: _____ ZIP: _____________ COUNTY: ____________________
WAGES: PER HOUR:
____
WEEKLY WAGE: ___________________________
DATE OF ACCIDENT (LAST EXPOSURE):
_______
BODY PART (S) INJURED:
INJURY: _______________________________________________________________________________________
LOCATION OF ACCIDENT:
HOW DID ACCIDENT OCCUR:
DATE REPORTED:
TO WHOM: ____________________
POSITION: __________________________
WITNESSES:
DATE STOPPED WORK:
DATE RETURNED TO WORK: ________________________
TEMPORARY DISABILITY BENEFITS PAID: YES ____ NO ____ BY INS CO _______ STATE TDB _________
TDB PAID: FROM:
TO:
LENGTH OF EMPLOYMENT:
DATE STARTED:
_______
NAMES/ADDRESSES OF DOCTORS/HOSPITALS
1.
______________________________________________________________________________________________
TREATMENT FROM:
TO:
WAS TREATMENT AUTHORIZED?
YES (
)
NO (
)
2.
______________________________________________________________________________________________
TREATMENT FROM:
TO:
WAS TREATMENT AUTHORIZED?
YES (
)
NO (
)
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Parent category: Business