Workers’ Compensation Claim Form

Employee Information

Full Name Home Address Phone Number Email Date of Birth Employee ID/Number

Job & Employer Information

Employer/Company Name Supervisor Name Job Title Start Date

Injury/Accident Information

Date of Injury/Accident Time of Injury/Accident Location (Street Address, City) Type of Injury Describe What Happened Part(s) of Body Injured Witness(es)

Medical Treatment

Date First Treated Physician/Hospital Name Describe Medical Treatment

Other Information

Date Reported to Employer Did you lose time from work? Yes No If yes, dates work missed Additional Comments/Information

Employee Signature Date