Workers’ Compensation Claim Form
Hospitality Workers
Employee Information
Name
Date of Birth
Job Title
Employee ID
Contact Number
Address
Employer Information
Employer Name
Workplace Address
Supervisor/Manager Name
Contact Number
Injury/Illness Information
Date of Injury/Illness
Time of Injury (if applicable)
Location of Incident
Describe the Injury/Illness
How did the incident occur?
Witnesses (if any)
Medical Treatment
Were you treated by a medical professional?
Yes
No
Name of Medical Facility/Provider
Date of First Treatment
Additional Details
Time Work Was Missed (if applicable)
Additional Comments
Declaration
Signature
Date