Get Workers' Compensation Complaint

Filling out the Workers' Compensation Complaint online can help you ensure that your claims are processed effectively and efficiently. This guide provides step-by-step instructions on each section of the form to assist you through the process with confidence.

Follow the steps to complete the Workers' Compensation Complaint online

1. Click the ‘Get Form’ button to obtain the form, allowing you to open it in your preferred editor.
2. Begin completing the form by indicating your type of injury. You can select from options like 'Accidental Work Injury' or 'Occupational Disease'.
3. Provide your full name, mailing address, city, state, and zip code. Ensure that your contact number is included.
4. Fill in your date of birth and age, and specify your sex.
5. Enter your social security number and the full name of your employer, along with their address and contact details.
6. List the name of the insurance carrier, their address, and telephone number.
7. Document the date of the accident along with the city and county where it occurred.
8. Indicate your job title at the time of the accident, your average weekly wage, and the weekly compensation rate.
9. Provide detailed information about how the accident occurred, the nature of the injury, and the specific body parts that were injured.
10. List the name and address of your treating doctor(s) and the first date you were unable to perform your job duties.
11. Include the date of your maximum medical improvement and your impairment rating, if applicable.
12. Indicate whether you have been released to work by a doctor, and if so, provide the release date.
13. Specify whether you have returned to work since the accident, including the date you returned.
14. Fill in your current employer's name and address and your highest level of education completed.
15. In the benefits section, check all that apply to your claim, including types of disability and medical benefits sought.
16. Clearly state all reasons supporting your complaint, providing details as necessary.
17. If needed, indicate whether an interpreter is required for hearings and specify the language.
18. Complete the Medicare eligibility questions to determine your benefits eligibility.
19. Lastly, sign the document, and ensure the signature of your attorney is included, along with their contact information.
20. Once everything is filled out, you can save your changes, download, print, or share the form as needed.

Complete the Workers' Compensation Complaint online today and ensure your claims are properly submitted.