Workers’ Compensation Claim Intake Form
Employee Information
Full Name
Employee ID
Address
Phone Number
Email Address
Date of Birth
Incident Details
Date of Incident
Time of Incident
Location of Incident
Description of Incident
Injury Details
Type of Injury
Body Part(s) Affected
Medical Treatment Received
Supervisor/Manager Information
Supervisor Name
Supervisor Contact
Witnesses
Witness Name(s) and Contact Information
Additional Information
Additional Comments or Information