Workers’ Compensation Claim Form
for Warehouse Employees

Employee Information

Full Name Employee ID Department Phone Number Email

Accident/Injury Details

Date of Incident Time of Incident Location (within warehouse) Describe What Happened Type of Injury Body Part(s) Affected

Medical Attention

Did you seek medical attention? Yes No Describe medical treatment received (if any)

Witness Information

Witness Name(s) Witness Contact Information

Additional Comments

Additional Information/Comments

Employee Signature

Signature Date