Get Form C 23437

Filling out the Form C 23437 is essential for reporting workers' compensation injuries. This guide provides clear and detailed steps to help you complete the form accurately and efficiently online.

Follow the steps to fill out the Form C 23437 online.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by entering the account and accident information, including the caller's phone number, title, name, and email address.
3. Fill in details about the employment state, subsidiary name, and subsidiary's address, ensuring you specify if the accident occurred at the reported location.
4. Next, provide the parent company or insured's name and the location code, followed by the policy symbol and number.
5. Document the nature of the business along with the date and time of the injury, and include a detailed accident description.
6. Proceed to the employee information section, starting with the injured employee’s Social Security number, name, gender, and date of birth.
7. Complete the employee's mailing and home addresses, including home phone and email addresses.
8. For employee job information, indicate the employment status (full-time, part-time, or other), department when injured, and regular occupation.
9. List the regular work schedule, including hours per day and days per week, and denote wage information.
10. Fill in the date of hire and if unknown, provide the length of employment in years and months, along with the supervisor's contact details.
11. In the accident information section, note the date the claim was reported, whether the injury was fatal, and any time lost from work.
12. Answer questions regarding the employee's current work status and whether they are back at work or on light duty.
13. Provide details about the cause of the accident and any witness information if applicable.
14. Complete the injury information by noting the part of the body injured and the nature of the injury, including any prior conditions.
15. Detail the treatment information, including the first treatment date, facility name, and physician involved.
16. Finally, specify who the primary contact for the claim is, including their name, title, phone number, and email.
17. Once all sections are completed, save changes, download, print, or share the Form C 23437 as necessary.

Begin completing the Form C 23437 online today to ensure timely reporting of workers' compensation injuries.