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