Form Wc-9 - Injured Employee'S Report Of Injury Form printable pdf download

Injured Employee's Report of Injury

A report of accidental injury was submitted by your employer. Payment of disability compensation and/or medical expenses

will be considered after this completed form and other information are received.

1. Full name of injured employee:_______________________________________________________________________

2. Employee's address:_______________________________________________________________________________

3. Telephone: Home: (_____) ______________________________;

Work: (_____) ____________________________

4. Employer/Agency: _________________________________________________________________________________

5. Job Title:_______________________________________

Employee ID # or SSN:____________________________

6. Date and time of accident: _______________________________________

7. Missed work from: ________________________________________ thru ____________________________________

8. Date returned to work: ____________________

If not, expected return to work date: ________________________

9. Describe the accident: (What happened, where, how, witnesses):

___________________________________________________________________________________________________

10. What injuries were incurred?________________________________________________________________________

11. Name/address of attending and/or subsequent physicians or hospitals:

___________________________________________________________________________________________________

12. Have you received workers compensation benefits before? If so, provide details such as employer, carrier, nature and

dates of injuries.

___________________________________________________________________________________________________

To claim compensation in accordance with Workers Compensation, sign and return this form to:

State Self-Insurance Fund

Division of Personnel Services

Room 951-S-Landon State Office Building

900 SW Jackson

Topeka, Kansas 66612-1251

Tel: (785) 296-2364

Fax: (785) 296-6995

AUTHORIZATION

I hereby authorize and request any physician or hospital to permit a representative of the State Self-Insurance Fund to be

furnished a copy of all medical records in connection with any past or present medical treatment associated with this injury. I am

willing that a photocopy or fax of this authorization be accepted with the same authority as the original.

Signed: ________________________________ Date: ____________________

Form WC-9 (Rev. 02/06)

Form Wc-9 - Injured Employee'S Report Of Injury Form