Workers’ Compensation Claim Form
for Construction Workers
Worker's Full Name
Employee ID
Job Title
Date of Birth
Employer/Company Name
Site Location
Supervisor's Name
Date of Incident
Time of Incident
Location of Incident (on site)
Description of Incident
Description of Injuries
Medical Attention Received
None
First Aid
Hospital
Other
Witnesses (Names & Contact Info)
Additional Information
Worker’s Signature
Date