Workers’ Compensation Coordination of Health Benefits Form
Employee Information
Employee Name
Date of Birth
Phone Number
Address
City
State
Zip Code
Employee ID
Social Security Number
Workers’ Compensation Information
Date of Injury/Illness
Claim Number
Employer Name
Employer Contact
Health Insurance Information
Primary Health Insurance Carrier
Policy/Group Number
Subscriber Name
Relationship to Employee
Details Regarding the Illness or Injury
Description
Coordination Information
Have you filed a workers’ compensation claim for this injury/illness?
Yes
No
If no, reason for not filing
Employee Signature
Date