Get Employee Claim Form

Completing the Employee Claim Form online is a crucial step in applying for workers' compensation benefits due to a work-related injury. This guide will provide you with a clear and detailed explanation of each section of the form to ensure your submission is accurate and complete.

Follow the steps to fill out the Employee Claim Form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Read the instructions carefully before proceeding to each section to ensure you understand what information is required.
3. In Section A, enter your personal information: full name, date of birth, social security number, mailing address, phone number, gender, and whether a translator is needed for a board hearing.
4. In Section B, provide details about your employer at the time of injury, including the employer's name, phone number, address, hiring date, supervisor's name, and information about any other employers.
5. In Section C, describe your job title, typical activities performed, work status (full-time, part-time, etc.), gross pay per pay period, payment frequency, and whether tips or lodging are received.
6. In Section D, detail the injury or illness, including the date and time, location, what you were doing at the time of injury, how the injury occurred, and the nature of the injury.
7. In Section E, address your work status following the injury, specifically if you stopped working, whether you returned to work, who you work for now, and current gross pay.
8. In Section F, input information about any medical treatment received, including dates, locations, ongoing treatment status, and prior injuries or illnesses that may be relevant.
9. Review all information entered for accuracy before submitting. Once completed, save the changes, download, print, or share the form as necessary.

Complete your Employee Claim Form online today to ensure your application for benefits is submitted accurately and efficiently.