Workers’ Compensation Insurance Claim Form
Employee Information
Full Name
Employee ID
Phone Number
Email Address
Address
Employer Information
Company Name
Contact Person
Phone
Email
Address
Incident Details
Date of Incident
Time of Incident
Location of Incident
Describe the Incident
Were there witnesses?
Yes
No
If yes, list witnesses
Injury Information
Type of Injury
Body Part(s) Affected
Describe the Injury
Was medical treatment provided?
Yes
No
If yes, where?
Signature
Employee Signature
Date