Workers’ Compensation Psychiatric Trauma Claim

Workers’ Compensation Psychiatric Trauma Claim
Submit your claim for psychiatric trauma experienced in the workplace. Please provide accurate and complete information to support your claim.
Full Name
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Contact Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Employer Name
Job Title/Position
Date of Incident
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Location of Incident
Describe the incident and how it caused psychiatric trauma
Describe your symptoms related to the incident
Have you sought medical or psychological treatment for this incident?
If yes, please provide the provider’s name and treatment details
Were there any witnesses to the incident?
If yes, please provide witness names and contact information
Upload supporting documents (optional)
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