| *Indicates Required Field |
|
| Preparer's Information: |
| *Preparer's Name |
|
| *Preparer's Phone Number |
|
| *Preparer's Title |
|
| *Date Prepared |
|
| *Preparer's email |
|
|
| General Information: |
| *Policy Number |
|
| *Benefit State |
|
| *Accident Date |
|
| *Accident Time |
|
|
| Employer Information: |
| *Name |
|
| *Federal Employer Identification(FEIN) |
|
State UI Registration#
(Required for NY,IA, MI, WI, MN) |
|
| *Mailing Address |
|
| *City |
|
| *State |
|
| *Zip Code |
|
| *Phone Number |
|
| Nature of Business |
|
| *Contact Person |
|
| *Contact Phone Number |
|
| Are your Workers Compensation panels posted? |
Yes
No
|
Are your Notification Forms signed? (For PA) |
Yes
No
|
|
| Employee Information: |
| *First Name |
|
| *Last Name |
|
| *Mailing Address |
|
| *City |
|
| *County |
|
| *State |
|
| *Zip Code |
|
| *Phone Number |
|
| *Social Security # |
|
| Age |
|
| Gender |
Male
Female
|
| Birth Date |
|
If employee is under age 18,
please enter certificate # |
|
| Marital Status |
Single
Married
Divorced
Widowed
|
| *Occupation |
|
| *Department |
|
| Hire Date |
|
| State of Hire |
|
| Date in Current Job |
|
| Length in Current Job |
|
| *Date Injury Reported to Employeer |
|
| Employee Status |
Full Time
Part Time
Volunteer
Seasonal
Other
|
| Is the Employee Owner/Officer, Partner? |
Yes
No
|
| Was employee paid for the day of injury? |
Yes
No
|
| Days Worked/Week |
|
| Hours Worked/Day |
|
| Hours Worked/Week |
|
| Wages/Hour |
|
| Wages/Day |
|
| Average Gross Wage/Week |
|
| Salary/Month |
|
| *Has Employee Returned to Work? |
Yes
No
|
| If Yes, Indicate Date & Time |
|
| Return Wage |
|
| Paid While Injured? |
Yes
No
|
| Total Dependents |
|
|
| Accident Information: |
| Accident Location (address/department) |
|
| Accident County |
|
| Accident Description |
|
List All Equipment Employee Was Using at
Time of Accident |
|
Work Process Employee Engaged In at
Time of Accident |
|
| Were Safeguards Provided? |
Yes
No
|
| Were Safeguards Used? |
Yes
No
|
| Was Accident on Premises? |
Yes
No
|
Time Shift Begins
(Indicate AM/PM) |
|
Time Reported
(Indicate AM/PM) |
|
| Supervisor |
|
| Date Last Worked |
|
| Is this a Lost Time Claim? |
Yes
No
|
| If Yes, Date Disability Began |
|
| Fatal? |
Yes
No
|
| If Yes, Date of Death |
|
| If Yes, Name and Address of Nearest Relative |
|
| Did Employee Commit an Unsafe Act? |
Yes
No
|
| Nature of Injury/Body Part |
|
| Object/Substance Involved |
|
| Reason to doubt validity of claim |
Yes
No
|
|
| Witness Information: |
| Witness Name |
|
| Mailing Address |
|
| City |
|
| State |
|
| Zip Code |
|
| Phone Number |
|
|
| Medical Provider Information: |
| Is This Claim For Reporting Purposes Only? |
Yes
No
|
| Provider Name |
|
| Mailing Address |
|
| City |
|
| State |
|
| Zip Code |
|
| Phone Number |
|
| Was Employee Treated In An Emergency Room? |
Yes
No
|
| Was Employee Hospitalized Overnight? |
Yes
No
|
|
| Agent Information: |
| Name |
|
|
| Comments: |
|
|
