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

Field	Descrip­tion
Employ­ee Name	Full name of the injured employee
Date of Birth	Employ­ee’s date of birth
Social Secu­ri­ty Number	Employ­ee’s SSN for iden­ti­fi­ca­tion and tax purposes
Address	Employ­ee’s cur­rent address
Phone Num­ber	Employ­ee’s con­tact phone number
Email Address	Employ­ee’s email address for communication
Occu­pa­tion	Employ­ee’s job title and description
Employ­ment Start Date	The date when the employ­ee start­ed work­ing for the company
Date of Injury	The date on which the injury occurred
Time of Injury	The time at which the injury occurred
Loca­tion of Injury	The spe­cif­ic place where the injury took place
Injury Descrip­tion	A detailed descrip­tion of the injury and how it occurred
Wit­ness­es	Names and con­tact infor­ma­tion of any wit­ness­es to the incident
Med­ical Treatment	Infor­ma­tion on med­ical treat­ment received, if any
Treat­ing Physician	Name and con­tact infor­ma­tion of the physi­cian treat­ing the injured employee
Work Restric­tions	Any work restric­tions due to the injury
Lost Time from Work	Infor­ma­tion on any time missed from work due to the injury
Employ­er Name	Name of the com­pa­ny or orga­ni­za­tion employ­ing the injured worker
Employ­er Address	Address of the com­pa­ny or organization
Employ­er Phone Number	Con­tact phone num­ber for the com­pa­ny or organization
Super­vi­sor Name	Name of the injured employ­ee’s direct supervisor
Super­vi­sor Phone Number	Con­tact phone num­ber for the employ­ee’s supervisor

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