Workers’ Compensation Claim Form for Landscaping Employees
Employee Information
Full Name
Address
Phone Number
Job Title/Position
Employee ID Number
Incident Information
Date of Incident
Time of Incident
Location of Incident
Description of Incident
Landscaping Task Being Performed
Injury Information
Type of Injury
Body Part(s) Injured
Describe the Injury
Medical Treatment Received
Medical Provider Name & Address
Number of Workdays Missed
Witness Information
Witness Name(s)
Witness Contact Information
Supervisor/Manager Report
Supervisor/Manager Name
Comments
Date Reported