Worker Compensation Claim Form
Employee Name
First Name
Last Name
Employee Phone Number
Format: (000) 000-0000.
Employee Email
example@example.com
Employee Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date and Time of Accident/Injury
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Describe how the injury happened
Location where the injury happened
Provide information that you should've done to prevent this
Do you have any other information that you want to share?
Date Signed
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Employee Signature
Employer Section
Employer Name/Company Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date when the company was informed about the accident/injury?
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
When did the company provided the claim form?
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
When did the employee received the claim form?
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Insurance Policy ID
Employer Representative Name
First Name
Last Name
Position/Title
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date Signed
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature of Employer (representative)
Submit
Should be Empty: