Get Employee Statement Form - Welcome To Hostos Community College ... - Hostos Cuny

The Employee Statement Form is an essential document for employees at Hostos Community College, designed to initiate claims related to workplace injuries. This guide offers clear instructions on how to accurately fill out the form to ensure a smooth claim process.

Follow the steps to successfully complete your Employee Statement Form online.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by entering your full name in the ‘Injured Employee Name’ section, including your first name, middle initial, and last name.
3. Provide your full address, including apartment number, street, city or town, state, and zip code.
4. Fill in your social security number accurately as per the required format.
5. Document the date of the accident or injury using the format MM DD YYYY.
6. Indicate the time of the accident in either AM or PM format, along with the hours and minutes.
7. List the phone numbers in the home and work sections, including area codes and extensions if applicable.
8. Specify the date of the statement by entering it in MM DD YYYY format.
9. Note the number of witnesses present at the time of the accident.
10. Complete the superior notified section with the first name, middle initial, last name, title, work telephone number, and date first notified in MM DD YYYY format.
11. Describe the location where the accident occurred in detail.
12. Thoroughly explain how the accident happened.
13. Identify the object or substance that caused the injury.
14. Describe the nature and extent of your injury, including the affected body parts.
15. Print your name in the specified section, provide your signature, title, telephone number, and the date of signing.
16. After filling out all sections, save your changes, and proceed to download, print, or share the completed form as needed.

Complete your forms online to ensure a smooth submission process.