Get Workers Comp Claim Form

Filing a workers compensation claim online can be a straightforward process when you understand each section of the claim form. This guide will provide you with step-by-step instructions to ensure that your claim is completed accurately and efficiently.

Follow the steps to successfully complete your Workers Comp Claim Form

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the injured worker's information. This includes their name, Social Security number, and address. It is crucial to enter these details accurately as they will be used for identification purposes.
3. Next, provide the contact information of the injured worker. Include both home and work phone numbers, and select the correct gender and marital status. Also, indicate the number of dependents the worker has.
4. Enter the personal details such as the worker's date of birth, date of hire, job title, and wage information. Ensure that you specify the regular work hours including the starting and ending times, as well as the total hours worked per week.
5. Document the injury details next. Fill in the date and time of the incident, and the location where it occurred. It is important to also include any witnesses' names and contact numbers.
6. Describe how the injury happened in detail. Provide a comprehensive account of the incident to help in processing the claim.
7. Specify the type of injury (e.g., cut, burn) and detail the exact part of the body that was injured. This information is critical for the claim evaluation.
8. Record the name and address of the physician or hospital that treated the injury. This will help facilitate communication regarding medical treatment details.
9. Indicate any missed work time due to the injury and provide a return to work date if known. This helps in determining the compensation amount.
10. Once all fields are completed, review the entire claim form for accuracy. You can then save your changes, download, print, or share the form as needed.

Take the first step towards filing your workers compensation claim by completing the necessary documents online.