What is your Workers’ Compensation policy number?

If policy number is not available, what is your Federal ID number?

What was the date injury?

In what State did the Injury Occur?

What is the business name?

Briefly describe the nature of business:

What is your name? (first, last)

What is your telephone number, including area code?

What is your title?

What is the injured employee’s name? (first, last)

What is the injured employee’s social security number?

What is the injured employee’s home telephone number, including area code?

What is the injured employee’s date of birth?

Is the injured employee a male or a female?

What is the injured employee’s home address? Include city, state & zip code

What is the approximate time injury occurred?

Will the injured employee miss time from work? Yes	No If yes, how many days?

What was the last day the injured employee worked due to the injury?

What date did the injured employee return to work, or is expected to return to work?

Was the injured employee paid in full for the day of injury?

Was the injury fatal? Yes No If yes, what is the date of death?

How did the accident happen?

Was the employee injured on the Employer’s premises?

If ‘No’, provide the full address where the injury did occur. Include city, state & zip code.

What body part or parts were affected?

What type of injury did the employee sustain? For example: contusions, lacerations, or burns.

What is the injured employee’s job title or occupation?

What is the full address of the location that the injured employee was hired? Include city, state & zip code

If applicable, what is the department/location code?

What is the injured employee’s date of hire?

What is the injured employee’s hourly rate?

What time did the injured employee begin work on day of injury?

What date was the injury reported to the employer?

Did the injured employee seek medical treatment?

If so, what type of medical treatment did the employee seek? Minor Medical Treatment by Employee; Minor Medical Treatment by Clinic/Hospital; Emergency Care; Hospitalization for more than 24 hours

If known, what is the name of the Clinic or Hospital employee was first treated?

If known, what is the name of the treating physician?

What is your email address?

Is there any additional information that may be pertinent to this claim?