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Workers Comp Intake Form

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Last Updat­ed on June 19, 2023 

In case of injury and to file your claim, here is some of the data you must main­tain to assist you in fil­ing a work­ers’ comp claim.

Reporting Workers Comp Injury

FieldDescrip­tion
Employ­ee NameFull name of the injured employee
Date of BirthEmploy­ee’s date of birth
Social Secu­ri­ty NumberEmploy­ee’s SSN for iden­ti­fi­ca­tion and tax purposes
AddressEmploy­ee’s cur­rent address
Phone Num­berEmploy­ee’s con­tact phone number
Email AddressEmploy­ee’s email address for communication
Occu­pa­tionEmploy­ee’s job title and description
Employ­ment Start DateThe date when the employ­ee start­ed work­ing for the company
Date of InjuryThe date on which the injury occurred
Time of InjuryThe time at which the injury occurred
Loca­tion of InjuryThe spe­cif­ic place where the injury took place
Injury Descrip­tionA detailed descrip­tion of the injury and how it occurred
Wit­ness­esNames and con­tact infor­ma­tion of any wit­ness­es to the incident
Med­ical TreatmentInfor­ma­tion on med­ical treat­ment received, if any
Treat­ing PhysicianName and con­tact infor­ma­tion of the physi­cian treat­ing the injured employee
Work Restric­tionsAny work restric­tions due to the injury
Lost Time from WorkInfor­ma­tion on any time missed from work due to the injury
Employ­er NameName of the com­pa­ny or orga­ni­za­tion employ­ing the injured worker
Employ­er AddressAddress of the com­pa­ny or organization
Employ­er Phone NumberCon­tact phone num­ber for the com­pa­ny or organization
Super­vi­sor NameName of the injured employ­ee’s direct supervisor
Super­vi­sor Phone NumberCon­tact phone num­ber for the employ­ee’s supervisor

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Tags: #WorkersCompClaims

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