Workers Compensation Claim Form (Page 2 of 3) in pdf

Workers Compensation Claim Form Page 2

Workers' Compensation Claim Form

EMPLOYEE'S NAME

DATE OF INJURY/ILLNESS:

First

Last

D. EMPLOYEE'S INJURY OR ILLNESS continued

10. What was the employee doing when he/she was injured or became ill?(e.g., unloading a truck, stocking a shelf, typing annual report)

11. How did the injury/illness occur? (e.g., the employee tripped over a pipe and fell on the floor):

12. Explain fully the nature of the employee's injury/illness; list body parts affected. (e.g., twisted left ankle and cut to forehead):

13. Was an object (e.g., forklift, hammer, acid) involved in the injury/illness?

Yes

No If yes, what was it?

14. Was the injury the result of the use or operation of a licensed motor vehicle?

Yes

If yes,

employee's vehicle

employer's vehicle

other vehicle

License Plate Number (if known):

If employer's vehicle was involved give name and address of your motor vehicle insurance carrier:

Yes

15. Did the injury/illness result in the employee's death?

If yes, what was the date of death?:

Name and address of nearest relative:

E. MEDICAL TREATMENT

None received

Unknown

1. What was the date of the employee's first treatment?

2. Where did the employee receive first medical treatment for this injury/illness?:

On site

Doctor's office

Emergency Room

Clinic/Hospital/Urgent Care

Hospital Stay over 24 hours

Unknown

Who treated the employee and where?

3. Is the employee still being treated for this injury/illness?

If yes, name and address of treating doctor(s):

Yes

Unknown

Workers' Compensation Claim Form

Page 2 of 3

Workers Compensation Claim Form Page 2