Workers' Compensation Claim Severity Change Report Form
Use this form to report a change in the severity of an existing workers' compensation claim.
Claim Number
*
Employee Name
*
First Name
Last Name
Date of Severity Change
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reporter Name
*
First Name
Last Name
Reporter Email
*
example@example.com
Previous Severity Level
*
Please Select
Minor
Moderate
Major
Critical
New Severity Level
*
Please Select
Minor
Moderate
Major
Critical
Reason for Severity Change
*
Additional Comments (optional)
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Submit Report
Should be Empty: