Workers’ Compensation Claim Frequency Report
Submit details of workers’ compensation claims for your organization’s reporting period.
Company/Organization Name
*
Reporting Period Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reporting Period End Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Person Full Name
*
First Name
Last Name
Contact Email Address
*
example@example.com
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Total Number of Claims Reported
*
Breakdown of Claims by Type
*
Rows
Medical Only
Lost Time
Denied
Other
Number of Claims
Number of Claims by Status
*
Rows
Open
Closed
Number of Claims
Claims by Department or Location (if applicable)
Have there been any repeat claims from the same employee(s) during this period?
*
Yes
No
Comments or Explanations (e.g., reason for high claim frequency, corrective actions taken)
Submit Report
Should be Empty: