Workers’ Compensation Claim Form for Remote Workers
Employee Information
Full Name
Employee ID
Email Address
Phone Number
Home Address
Incident Details
Date of Incident
Time of Incident
Location (e.g., Home Office, Kitchen, etc.)
Description of Incident
Describe the Injury
Was anyone else involved?
Medical Attention
Did you seek medical attention?
Yes
No
If yes, provide details (e.g., hospital/doctor visited, treatment received)
Work Impact
Did the injury cause you to stop working?
Yes
No
If yes, date/time stopped and resumed work
Additional Comments