Get Employee Questionnaire Form New - Mcim

This guide provides clear and detailed instructions for users on how to successfully fill out the Employee Questionnaire Form New - Mcim online. Follow these steps to ensure all necessary information is accurately provided, facilitating a smooth process for your submission.

Follow the steps to fill out the form online:

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. In the 'Employee Info' section, provide your first name, middle initial, last name, street or P.O. Box address, phone number, city, state, zip code, social security number, date of birth, age, gender, marital status, driver’s license number, spouse’s name, and names and birth dates of any dependents.
3. In the 'Accident or Occupational Disease & Medical Treatment' section, fill in the date of the injury, day of the week, approximate time, city, and state of the incident. Include the return to work date and last day of work or estimated return to work date, as applicable.
4. Detail the nature of the injury or occupational disease and provide the date and place of first treatment. List all doctors you have treated for this accident, including their names, addresses, and phone numbers.
5. Describe how the accident or occupational disease occurred. If more space is needed, use an additional piece of paper.
6. Indicate if you are receiving Social Security Disability Benefits (SSDB). If so, provide the amount of monthly benefit and the date you started receiving benefits. Also, indicate if you have applied for Social Security or SSDB and provide the date applied.
7. In the 'Employment Info' section, fill in the name of your current employer, your supervisor’s name, your date of hire, the city and state, street address or P.O. Box, zip code, rate of pay, whether you have health insurance, and if your wages continued.
8. List your second employer and any additional income. Provide details about prior employers, including addresses, phone numbers, job duties, and wage information.
9. Include any other job skills not previously mentioned, as well as any volunteer work or hobbies you have done.
10. In the 'Notification of Incident' section, provide the name and title of the person you reported the accident to, the date it was reported, and the names and contact information of any witnesses.
11. State whether you are still under medical care for the incident and provide details about your next appointment or the last appointment if applicable.
12. Indicate if you obtained a work status slip from your doctor and provided it to your employer.
13. List all previous injuries, surgeries, and serious illnesses, and provide any additional comments.
14. Finally, sign and date the form to complete your submission.

Complete your Employee Questionnaire Form New - Mcim online today to ensure a streamlined claims process!