Case Management

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Preparer's Information

 
 
 
 
 

General Information

 
 
 

Employer Information

 
 
 
 
 
 
 
 
 

Are your Workers Compensation panels posted?

Are your Notification Forms signed? (For PA)

Employee Information

 
 
 
 
 
 
 
 

Gender

 

Marital Status

Employee Status

Is the Employee Owner/Officer, Partner?

Was employee paid for the day of injury?

Has Employee Returned to Work?

Paid While Injured?

Accident Information

 

Were Safeguards Provided?

Were Safeguards Used?

Was Accident on Premises?

Is this a Lost Time Claim?

Fatal?

Did Employee Commit an Unsafe Act?

Reason to doubt validity of claim

Witness Information

Medical Provider Information

Is This Claim For Reporting Purposes Only?

Was Employee Treated In An Emergency Room?

Was Employee Hospitalized Overnight?

Agent Information

Comments

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