Workers’ Compensation Insurance Claim Document
Employee Information
Employee Name
Employee ID
Job Title
Department
Phone
Email
Home Address
Incident Details
Date of Incident
Time of Incident
Location
Describe the incident
Describe the injury
Medical Treatment
Was medical treatment provided?
Yes
No
Name of facility/doctor
Treatment Date
Phone (medical provider)
Witness Information
Witness Name
Phone
Statement
Employer Information
Employer Name
Contact Person
Phone
Email
Address
Date
Signature