Workers’ Compensation Claim Form
for Temporary Workers
Temporary Worker Information
Full Name
Date of Birth
SSN/ID
Address
Phone
Email
Temporary Agency Information
Agency Name
Contact Person
Phone
Email
Client Company Information
Company Name
Worksite Address
Supervisor
Department
Incident Details
Date of Incident
Time of Incident
Location of Incident
Description of Incident
Injury Information
Describe the Injury
Body Part(s) Affected
Action Taken
Medical Treatment
Facility/Doctor Visited
Date of First Treatment
Witness Information
Witness Name(s)
Witness Contact
Certification
Temporary Worker Signature
Date