Workers’ Compensation Claim Form
for Retail Employees
Employee Information
Full Name
Employee ID
Address
Phone Number
Job Title/Position
Department/Store Location
Incident Details
Date of Incident
Time of Incident
Location of Incident
Describe How the Incident Occurred
Type of Injury/Injuries Sustained
Medical Information
Describe Any Medical Treatment Received
Healthcare Provider/Facility Name
Provider Address
Witness Information
Witness Name(s)
Witness Contact Information
Additional Comments
Employee Signature
Date