Get C L A I M S A D M I N

Filling out the C L A I M S A D M I N is an essential step in reporting workplace injuries or illnesses effectively. This guide provides a step-by-step process to help users complete the form accurately and efficiently.

Follow the steps to fill out the C L A I M S A D M I N form online.

1. Click the ‘Get Form’ button to obtain the form and open it in your editing interface.
2. Begin by entering the employer's name and address, including the zip code, in the designated fields. Ensure that this information is accurate as it needs to match what is provided to the Department of Workforce Services.
3. Input the OSHA Log Number and Report Purpose Code as required. These numbers are crucial for tracking the claim and its relation to safety regulations.
4. Fill in the Employer's Location Address if it differs from the one you previously provided. This section is particularly important for record-keeping.
5. Enter the Jurisdiction Claim Number and the Insured Report Number in the correct fields, helping to identify the claim during processing.
6. Provide information regarding the Carrier/Administrator Claim Number, and include the appropriate details for the claims carrier such as name, address, and phone number.
7. Document the employee's information, starting with their full name, social security number, and date of birth. Be careful to input this information accurately as it is vital for the claim.
8. Record details about the injury or illness, including the date, time, and nature of the incident. Clearly describe the sequence of events and any specific activities the employee was engaged in at the time.
9. Indicate whether the injury occurred on the employer's premises and provide details of any witnesses to the incident.
10. After completing all fields, review the information for accuracy, save your changes, and prepare to download, print, or share the completed form as needed.

Complete your documents online to ensure timely submission and avoid delays.