Workers Compensation Claim Form
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3Workers' Compensation Claim Form
Workers' Compensation Claim Form
Entered By:
Reviewed By:
Record ID
WCB Case Number (if you know it):
Date of injury/illness:
Carrier Case Number (if you know it):
Date of this Report:
A. EMPLOYER INFORMATION
1. Employer:
2. Employer FEIN:
3. Mailing Address:
4. Location Address (if different):
5. Phone Number:
6. Nature of Business or Industry Code:
7. OSHA Case Number (if known):
8. NY UI Employer Reg Number:
B. INSURANCE CARRIER / SELF-INSURED EMPLOYER
If individually self-insured, enter your Board W Number and skip to Section C.
1. Board W Number: W
2. Carrier Group Name:
3. Policy Number:
Policy Period: From:
To:
4. If Carrier Unknown, Insurance Agent Name:
5. Phone Number:
C. EMPLOYEE'S PERSONAL INFORMATION
1. Name:
2. Date of Birth:
First
MI
Last
3. Mailing Address:
Street Address
City
State
Zip
Male
Female
4. Social Security Number:
5. Contact Phone Number:
6. Gender:
D. EMPLOYEE'S INJURY OR ILLNESS
hh
mm
hh
mm
:
AM
PM
:
AM
PM
1. Time of day employee began work on date of injury:
2. Time of injury:
Yes
No
3. Has the employee given you notice of Injury Illness?
If yes, notice was given to:
Orally
In writing
Date Notice Provided:
If available attach a copy of the employee's written notice and medical notes, and the employer's incident report.
Yes
No
4. Have you given the employee a Claimant Information Packet?
If yes give date:
5. Where did the Injury/illness happen (e.g., 1 Main St., Pottersville, at the front door):
Yes
No
6. Was this location where the employee normally worked?
If no why was the employee there?
Yes
No
Unknown
7. Employee's Supervisor:
8. Did supervisor see injury happen?
Yes
No
Unknown
9. Did anyone else see the injury happen?
If yes, give name(s)
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Workers' Compensation Claim Form
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