Form 7a Dcwc - Employee'S Claim Application - District Of Columbia Government printable pdf download

Form 7a Dcwc - Employee'S Claim Application - District Of Columbia Government

DISTRICT OF COLUMBIA GOVERNMENT

OFFICE OF WORKERS= COMPENSATION

Date of This Report

P.O. BOX 56098

WASHINGTON, D.C. 20011

Employee Social Security Number

(202) 576-6265

Employer Identification Number

Warning: It is a crime to provide false or

Insurer Number

misleading information to an insurer for the

purpose of defrauding the insurer or any other

person. Penalties include imprisonment and/or

fines. In addition, an insurer may deny

insurance benefits if false information

materially related to a claim was provided by

the applicant.

EMPLOYEE=S CLAIM APPLICATION

Employee Name

Employer Name

Insurer Name

and Address:

NOTICE TO EMPLOYER/INSURER

A CLAIM FOR WORKERS= COMPENSATION BENEFITS HAS BEEN FILED WITH THIS OFFICE. YOU HAVE 14 DAYS

FROM THE RECEIPT OF THIS NOTICE IF YOU HAVE NO PREVIOUS KNOWLEDGE OF INJURY OR ITS RELATIONSHIP

TO EMPLOYMENT, TO BEGIN VOLUNTARY PAYMENTS OF WORKERS= COMPENSATION BENEFITS TO THE ABOVE

NAMED EMPLOYEE, OR YOU MUST FILE A NOTICE OF CONTROVERSION, MEMO OF DENIAL OF BENEFITS, FORM

NO. 11 DCWC WITH THIS OFFICE. FAILURE TO PAY BENEFITS, UNLESS YOU CONTROVERT THE EMPLOYEE=S

RIGHT TO BENEFITS, WILL SUBJECT YOU TO PENALTIES UNDER THE ACT. YOU SHOULD CONTACT YOUR

INSURER IMMEDIATELY.

Date and Time of Injury

am/pm? Office Representative

Place where injury occurred:

Description of Injury:

THIS IS TO NOTIFY YOU

Employer

That while in the employ of the above named employer I sustained a disabling injury

or contracted an

occupational disease

as described above. The disability was caused by:

Treating Physician=s Name and Address

YOU SHOULD HAVE ALREADY FILED OR SHOULD

I HAVE FILED THIS CLAIM WITH THE

FILE EMPLOYEE=S NOTICE OF ACCIDENTAL INJURY

OFFICE OF WORKERS= COMPENSATION.

OR OCCUPATIONAL DISEASE, FORM NO. 7 DCWC.

(Employee=s Signature)

Form 7a Dcwc - Employee'S Claim Application - District Of Columbia Government

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