Workers’ Compensation Claim Form
Business Information
Business Name
Business Address
Contact Person
Phone Number
Email
Employee Information
Employee Name
Employee ID/Number
Employee Address
Phone Number
Job Title
Date of Employment
Injury/Illness Details
Date of Injury/Illness
Time
Location of Incident
Describe how the injury or illness occurred
Type and part of body affected
Witnesses (if any)
Medical Information
Was medical treatment provided?
Name/Address of Treating Physician or Facility
Any follow-up care required?
Additional Comments
Signature
Date