Workers’ Compensation Claim Form
Employee Information
Full Name
Employee ID
Address
Phone
Department
Position
Incident Details
Date of Incident
Time of Incident
Location of Incident
Supervisor’s Name
Describe What Happened
Describe the Injury
Witnesses (if any)
Medical Information
Was Medical Treatment Provided?
Yes
No
Medical Provider’s Name
Description of Treatment
Signature
Employee Signature
Date