Employer'S Questionnaire Template (Page 3 of 4) in pdf

Employer'S Questionnaire Template Page 3

PAGE NUMBER: 3

EMPLOYER’S QUESTIONNAIRE

CLAIM NUMBER: _______________

12. When were you first notified of the claimant’s injury and who notified you?

13. State the names, addresses and telephone numbers of all witnesses to or persons who have knowledge of

claimant’s accident and injuries.

14. If claimant’s injury involved a vehicle:

State who owned the vehicle and whether the claimant leased the vehicle. If there was a signed lease

agreement, attach a copy.

Was a police report made? If so, attach a copy.

Specify the addresses where the trip started and the trip destination.

15. Did the claimant request medical treatment for the injury? Attach a copy of all medical records, reports and bills

relating to the claimant’s injury.

16. State whether the claimant was hired as an employee or contracted as a subcontractor. Attach a copy of any job

application or written contract with the claimant.

17. Did you provide W-2s or 1099s to the claimant both for the year before and the year of claimant’s injury? If so,

attach copies.

18. Regarding claimant’s work:

Who hired the claimant?

Who was claimant’s foreman or supervisor?

19. Regarding claimant’s work at the time of his injury:

How many hours per week did claimant work?

Was claimant paid by the job or by the hour?

Did you withhold taxes and social security from claimant’s pay?

20. At the time of claimant’s injury, what was claimant earning per week? Attach copy of pay stubs or payroll

records for the 13 weeks prior to the date of claimant’s injury.

21. If you, your company or any private insurance company has paid for claimant’s medical treatment, lost time or

disability, state who has made such payments

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

Employer'S Questionnaire Template Page 3