Workers’ Compensation Claim Form for Freelancers
Freelancer Information
Full Name
Address
Phone Number
Email
Project/Client Details
Client/Company Name
Project Description
Incident Details
Date of Incident
Location of Incident
Describe the Incident
Injury or Illness
Describe Injury or Illness
Medical Provider (if applicable)
Date of Treatment (if applicable)
Additional Information
Number of Work Days Lost
Additional Notes
Signature
Date