Workers Compensation Claim Form Page 3
ADVERTISEMENT
1
2
3Workers Compensation Claim Form
Workers Compensation Claim Form
EMPLOYEE'S NAME
DATE OF INJURY/ILLNES
First
MI
Last
4. To your knowledge, did the employee have another work-related injury to the same body part or a similar illness while
working for you?
Yes
No
If yes, name the doctor(s) who treated the previous injuries/illness (if known):
F. RETURN TO WORK
Yes
No
1. Did the employee stop work because of his/her injury illness?
If yes, on what date?
2. Has the employee returned to work?
Yes
No
regular duty
limited duty
If yes, on what date?
3. If the employee has returned to limited duty what are his/her average gross earnings per week?
G. EMPLOYEE'S WORK INFORMATION on the date of the injury or illness
1. Date the employee was hired
2. What was the employee's job title?
3. What types of activities did the employee normally perform at work? (Attach job description if available.)
H. EMPLOYEE'S PAYROLL INFORMATION on the date of the injury or illness
1. Employee's gross pay in average week was
Yes
No
2. Did the employee receive lodging or tips in addition to pay
If yes, describe:
Full Time
Part Time
Seasonal
Volunteer
Other
3. Employee's job was (check one):
Mon.
Tues.
Wed.
Thurs.
Fri.
Sat.
Sun.
4. Which days of the week did the employee usually work?
Yes
No
5. Was the employee paid for a full day on the day of the injury/illness?
6. Did you continue to pay the employee after the injury/illness (e.g., sick leave, vacation, disability, regular salary)?
Yes
No
I. ADDITIONAL INFORMATION
Page 3 of 3
Workers' Compensation Claim Form
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal