Employee Statement Of Injury For Worker'S Comp Coverage printable pdf download

EMPLOYEE STATEMENT OF INJURY FOR WORKER’S COMP COVERAGE

Name__________________________________________D/O/B______________Daytime Phone #_________________________________

Home Address______________________________________________City/State_____________________________Zip_______________

Work Location and Address__________________________________________________________________________________________

Date of Hire__________________________ Job Title__________________________ Hr. per Wk_______________ Gender____________

Date of Injury_______________________Time:_______________________________SS#________________________________

Did this injury occur while you were performing your regular duties:

□ Yes

□ No

If no, what were you doing_____________________________________________________________________________

Location where injury occurred_________________________________________________________________________________

Describe exactly how injury occurred___________________________________________________________________________

__________________________________________________________________________________________________________

Was there any equipment involved:

□ Yes

□ No

If yes, what equipment?____________________________________

Describe the body part injured and mark the illustration on the separate page below_____________________________________

__________________________________________________________________________________________________________

Describe your symptoms (i.e., pain right knee, etc)_________________________________________________________________

__________________________________________________________________________________________________________

Did you report the injury when it occurred:

□ Yes

□ No

If yes, who and when did you report your injury to_________________________________________________________

If no, explain why it was not reported____________________________________________________________________

Witnesses to the incident_____________________________________________________________________________________

10.

Have you ever experienced the symptoms described in # 7

□ Yes

□ No

A. Describe the cause of your symptoms then___________________________________________________________________

_________________________________________________________________________________________________

Who treated you then □

Hospital Name_______________________________________________________________

□

Doctor’s Name_______________________________________________________________

□

Date_______________________________________________________________________

This statement is true and accurate to the best of my knowledge. _________________________________________

___________

Signature of Employee

Date

MEDICAL AUTHORIZATION FORM

I AUTHORIZE any licensed physician, medical practitioner, nurse, pharmacist, hospital, clinic, other medical or medically related facility, insurance or

reinsurance company, consumer reporting agency, employer or former employer that has any information as to the diagnosis, treatment or prognosis of

any physical or mental condition of me, and any information regarding my occupation and salary, to give any and all such information to Community of

Christ, or its representative. This authorization is to include speaking with above-named parties. A photographic copy of this authorization shall be valid

as the original.

Signature (Employee)_____________________________________________________ Date________________________________________________

Address_____________________________________________________________________________________________________________________