Claim Information
*Company Name and Address
*Submitted by and Contact Phone Number
Date of Injury/Illness:
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*Jurisdiction:
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Social Security Number:
*Employee First Name:
Employee Middle Name:
*Employee Last Name:
Gender
*Claimant Type
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Loss Type
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Claim Source
select


Injury Information
Time injury/illness occurred
Time employee began work
Date of Death
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Date last worked
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Date returned to work
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Date employer notified
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Date employee provided form
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Unable to work?
Paid full wages?
Salary continued?
Still off work?

Specific injury/illness and part of body affected, medical diagnosis if available
*Body Part
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Nature of Injury
select
Cause of Injury
select
Injury Description


Injury Location
Injury Address 1
On employer's premises?
Department where event or exposure occurred
Injury Address 2
Injury City
Other workers injured or ill in this event
Injury Zip
State


How Injury/Illness Occurred
Specific task the employee was performing when event or exposure occurred
Describe sequence of events. Specify object or exposure which directly produced the injury/illness
Physician First Name
Physician Address 1
Physician Last Name
Physician Address 2
Hospitalized as an inpatient overnight?
Physician Phone Number
Physician Address City
Hospital Name

Physician Address Zip
State
Employee treated in emergency room?


Employee Information
Employee Date of Birth
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Date Picker
Employee Phone Number
Supervisor First Name
Supervisor Email
Employee Address 1
Employee Work Phone
Supervisor Last Name
Supervisor Work Phone
Employee Address 2
Employee Mobile Phone
Title

Supervisor Fax
Employee Address City
Employee Fax Number
Occupation
select
Date of Hire
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Date Picker
Employee Address Zip
State


Wage Information
Employee usually works
hours/day
days/week
hours/week
Frequency
select
Employment status
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Gross wages/salary
Employee Wages

Other payments not reported as wages?

Class Code
Please Enter the Code