Workers’ Compensation Claim Reopening Request Form

Claimant Full Name

First NameLast Name

Claimant Contact Email

example@example.com

Claimant Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Mailing Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Employer Name

Claim Number

Date of Original Injury or Condition

Date

Date Claim Was Last Closed

Date

Reason for Reopening Request

Other

Describe the Change, Recurrence, or Worsening of Your Condition

Current Work Status

Other

Current Medical/Treatment Status

Other

Upload Supporting Documents (e.g., medical reports, treatment records)

Additional Comments or Information