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CASE MANAGEMENT REFERRAL
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Preparer's Information
Type of Claim:
<
Report Only
Telephonic Case Mgmt
Field Case Mgmt
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 #
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*
Address*
City*
State*
Zip Code*
Phone*
Social Security #
Age
Date of Birth*
If employee is under age 18, please enter certificate #
Gender
Male
Female
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 Employer*
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
Hours Worked/Week
Salary/Mont
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
Fatal?
Yes
No
If Yes, date of death
If yes, name and address of nearest relative
Did Employee Commit an Unsafe Act?
Yes
No
Object/Substance Involved
Reason to doubt validity of claim?
Yes
No
Witness Information
Witness Name
Address
City
State
Zip Code
Phone Number
Medical Provider Information
Is This Claim For Reporting Purposes Only?
Yes
No
Provider Name
Address
City
State
Zip Code
Phone Number
Was Employee Treated In An Emergency Room?
Yes
No
Was Employee Hospitalized Overnight?
Yes
No
Agent Information
Phone Number
Comments
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