Employer'S Questionnaire Template (Page 2 of 4) in pdf

Employer'S Questionnaire Template Page 2

PAGE NUMBER: 2

EMPLOYER’S QUESTIONNAIRE

CLAIM NUMBER: _______________

If you or your company were covered by workers’ compensation insurance at the time of the claimant’s injury,

state the following:

Name and address of insurance company.

Policy number and effective date.

Attach a copy of your policy.

If you presently have workers’ compensation insurance, state the name and address of the insurance company,

the policy number and effective date.

State the dates during which the claimant worked for you or your company.

At the time of claimant’s injury, were you engaged as a subcontractor for another company? If yes, state the

following:

Name, address and telephone number of the (general) contractor.

Name of the project you were working on and the address of the project.

Name and address of other companies working on the project.

Name and address of the customer or client of the project.

Attach copies of all contracts related to this project.

10. Describe claimant’s accident and identify the parts of the body which the claimant injured. State the date, time

and place of claimant’s accident and specify the address where the accident occurred.

11. State any reasons why you feel that this claim should be d enied. State all defenses to this claim.

MD WCC MD WCC H-38 5/05/06

Employer'S Questionnaire Template Page 2