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


Injury Information
Time injury/illness occurred
Time employee began work
Date of Death
Date last worked
Date returned to work
Date employer notified
Date employee provided form
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
Nature of Injury
Cause of Injury
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
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
Date of Hire
Employee Address Zip
State


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

Other payments not reported as wages?

Class Code
Please Enter the Code